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OBSTETRICS 

A TEXT-BOOK FOR THE USE OF STUDENTS 

AND PRACTITIONERS 


BY 

J. WHITRIDGE WILLIAMS 

PROFESSOR OF OBSTETRICS, JOHNS HOPKINS UNIVERSITY; 
OBSTETRICIAN-IN-CHIEF TO THE JOHNS HOPKINS 
HOSPITAL, BALTIMORE, MD. 


FIFTH ENLARGED AND REVISED EDITION 


WITH SEVENTEEN PLATES AND SIX HUNDRED AND NINETY 

ILLUSTRATIONS IN THE TEXT 



D. APPLETON AND COMPANY 

NEW YORK LONDON 


1923 


7?Gr52,4- 

,W7 

I 9 2J3 


COPYRIGHT, 1903, 1904, 1907, 1999, 1910, 1912, 1917, 1923, BY 

D. APPLETON AND COMPANY 


Printed in the United States of America 

OCT 28 73 

©C1A760536 


TO 

WILLIAM H. WELCH 

PROFESSOR OF PATHOLOGY, JOHNS HOPKINS UNIVERSITY 

AND 

WILLIAM T. COUNCILMAN 

PROFESSOR OF PATHOLOGY, HARVARD UNIVERSITY 

AS AN EXPRESSION OF RESPECT 


AND AFFECTION 




PREFACE TO THE FIFTH EDITION 


In this edition I have attempted to set forth, as fully as is possible 
within the limits of a textbook, the data upon which the science of 
obstetrics is based, and at the same time so to treat the practical aspects 
of the subject as to make the book a useful and conservative guide for 
the practitioner at the bedside. 


That insistence upon conservatism is particularly necessary is shown 
by the statistical studies of Howard and Eichel, which indicate that 
while the puerperal death rate had slowly, but progressingly, fallen 
down to 1916, a definite rise had occurred during the following five 
years, with the result, that childbirth was actually more dangerous in 
this country in 1921 than in 1916. Furthermore, their studies show 
that the death rate is greater in urban than in rural communities, and 
that while reasonably satisfactory results are obtained in the largest 
cities, in which a considerable proportion of deliveries are cared for in 
hospitals conducted by trained specialists, they are superior in country 
districts to those obtained in the medium-sized and small towns. 

As the reverse would naturally be expected, I am inclined to explain 
the apparent paradox by supposing that many practitioners in urban 
communities have been led astray by the teachings of those who regard 
labor as a pathological rather than a physiological process, with the 
result that interference upon insufficient indications is frequently under¬ 
taken by those who do not fully appreciate the risk involved. 

That such a supposition is not fanciful is indicated by the fact, 
that an inquiry by a committee of the Massachusetts State Medical 
Society into the puerperal death rate in that state during the year 
1921 showed that, after puerperal infection, cesarean section constituted 
the most frequent causes of death. 

For these reasons, while the technic of the various operative pro¬ 
cedures is described in all necessary detail, r have taken pains in stating 
the* indications for their employment to insist upon the greatest possible 
conservatism consistent with the welfare of the patient and her child. 

The book has been revised throughout, and every chapter has been 
subjected to such changes as were necessary to bring it into accord 
with the advances recorded up to date. 

The most radical changes have been made in the following sections: 
The development of the ovum and placentation; the employment oi 
the X-ray in the diagnosis of pregnancy and ol toetal syphilis; the 
technic and indications for podalic version; the indications for 
cesarean section; the toxemias of pregnancy; the prevention and treat¬ 
ment of po^ rtum hemorrhage, and the part played by syphilis in the 

causation of ctal death. 





Vlll 


PREFACE TO THE FIFTH EDITION 


The value of the sections upon the development of the ovum and 
upon the technic of podalic version has been greatly enhanced by original 
drawings kindly made by Mr. Max Broedel; while I am under many 
obligations to my former associate, Everett D. Plass, for assistance in 
revising the chapter upon the toxemias of pregnancy, and to my various 
assistants and my secretary for valuable aid. 

The book accurately represents the practice followed in The Woman’s 
Clinic of the Johns Hopkins Hospital and University, tempered by due 
consideration of the views of others, and I hope that it will prove con- 
tinuingly useful to students and practitioners. 

J. Whiteidge Williams 

Baltimore 








PREFACE TO THE FIRST EDITION 


In the following pages I have attempted to set forth, as briefly as 
seemed to be consistent with thoroughness, the scientific basis for and the 
practical application of the obstetrical art. 

Especial attention has been devoted to the normal and pathological 
anatomy of the generative tract. At the same time I have endeavored to 
present the more practical aspects of obstetrics in such a manner as to be 
of direct service to the obstetrician at the bedside. 

No pains have been spared in illustrating the work, although mere 
artistic effect has necessarily often been sacrificed to accuracy and practi¬ 
cal teaching qualities. With the exception of those relating to pure 
embryology, all illustrations representing microscopical sections have 
been drawn from my own specimens under my direct personal super¬ 
vision, and are accurate reproductions of the originals. The drawings 
and diagrams illustrating labor and its mechanism for the most part 
represent the woman on her back, thus affording a closer correspondence 
with the actual conditions encountered in practice. The representations 
of the various operative procedures have been redrawn from photographs 
taken from life. 

Although no attempt has been made to present a complete bibliog¬ 
raphy, I have endeavored to give at the end of each chapter such refer¬ 
ences to the early history, as well as to the most recent advances in each 
subject, as to enable the student to refer readily to the most important 
original sources. In order to insure accuracy, the individual articles 
have been consulted in every case. 

In conclusion, I desire to express my appreciation of the excellent 
work of Miss Katherine M. Montague and Mr. F. S. Lockwood in the 
preparation of the illustrations and to thank my various assistants and 
my stenographer for most valuable aid. I am under very many obliga¬ 
tions to my friend, Dr. Frank R. Smith, for the revision of the text and 
for many suggestions which .have added materially to its clearness. 


IX 



CONTENTS 


SECTION I 


Anatomy 

CHAPTER 

I. The Pelvis. 

Historical. 

General considerations. 

The pelvis from an obstetrical point of view 
Planes and diameters of the pelvis 

Pelvic inclination. 

The pelvic axis. 

Individual variations in fhe pelvis 
Sexual differences in the adult pelvis . 
Baeial differences in pelves .... 
Pelvis of the new-born child .... 
Transformation of fcetal into adult pelvis . 

II. The Female Organs of Generation . 

The external generative organs 

The vagina. 

The uterus. 

The fallopian tubes. 

The ovaries. 


PAGE 

1 

1 

2 

Q 

o 

4 

8 

10 

12 

13 

10 

17 

19 

26 

26 

35 

38 

56 

61 


SECTION 11 


Physiology and Development of the Ovum 

III. Menstruation and Ovulation.85 

Menstruation.85 

Belation between menstruation and ovulation . . . 89 

Migration of ovum ......... 93 

Place of meeting of ovum and spermatozoa ... 95 

IV. Maturation, Fertilization, and Development of Ovum . 100 

Maturation of ovum.100 

Fertilization of ovum.103 

Development of ovum.105 

Implantation of human ovum.Ill 

Formation of chorion and amnion..114 

Structure of chorion.126 

Structure of amnion ..131 

Decidua.132 

Development of placenta.140 

Placenta at full term.144 

Afterbirth.147 

Umbilical cord.149 

Umbilical vesicle.151 


xi 




















Xll 


CONTENTS 


CHAPTER 

Y. The Fcetus. 

Foetus in the various months of pregnancy . 

Weight of the new-born. 

Physiology of foetus. 


PAGE 

157 

157 

162 

166 


SECTION III 


Physiology of Pregnancy 


VI. Changes in the Maternal 
Pregnancy . 

* Uterus .... 
Tubes and ovaries 
Vagina .... 
Abdominal walls 
Breasts 

In rest of the body . 
General metabolism . 


Organism Besulting from 

.183 

.183 

.188 

.189 

.190 

.191 

.192 

.198 


VII. Diagnosis of Pregnancy, etc .206 

Positive signs of pregnancy.206 

Probable signs of pregnancy.210 

Presumptive signs of pregnancy.215 

Synopsis of signs and symptoms of pregnancy . . . 218 

Differential diagnosis of pregnancy.218 

Spurious pregnancy.219 

Duration of pregnancy.221 

Estimation of date of confinement.223 

VIII. Management of Normal Pregnancy .227 

IX. Presentation and Position of Fcetus .234 

Nomenclature.236 

Beasons for the predominance of head presentations . 239 

Diagnosis of presentation and position of foetus . . 241 


SECTION IV 
Physiology of Labor 

X. Physiology and Clinical Course of Labor .... 248 

Cause of the onset of labor.248 

Physiology of labor pains.253 

Physical changes during uterine contractions . . . 255 

Clinical course of labor.256 

Duration of labor.262 

XI. Forces Concerned in Labor .266 

Cervix in latter part of pregnancy.266 

Lower uterine segment. 267 

Changes in uterus during first stage of labor . . . 271 

Changes in uterus during second stage of labor . . . 274 

Forces concerned in labor.276 

Changes in vagina and pelvic floor during labor . . 278 




















CONTENTS 

CHAPTER 

XII. Mechanism of Labor in Vertex Presentations . 

Left and right occipito-anterior presentations 
Right and left occipitoposterior presentations 
Changes in shape of head. 

XIII. Mechanism of Labor in Face, Brow, and Breech Presenta¬ 


tions .307 

Face presentations.307 

Brow presentations.315 

Breech presentations.318 

XIV. Physiology and Management of Third Stage of Labor . 326 

Mechanism of separation of placenta.327 

Mode of extrusion of placenta.330 

Clinical picture of third stage of labor .... 334 

Management of third stage of lator.336 

XV. Conduct of Normal Labor.341 

Preparations for labor.341 

Conduct of'first stage of labor.345 

Conduct of second stage of labor.351 

Anesthesia.359 

Conduct of third stage of labor.365 

Repair of lacerated perineum.365 

XVI. The Puerperium.372 

Anatomical changes in the puerperium . . . . 372 

Clinical aspect of the puerperium.376 

Care of patient during puerperium.380 

XVII. The Newly Born Child.388 

Circulatory changes.388 

Care of the umbilical cord.389 

Care of eyes.391 

Stools and urine . . ..302 

Icterus.393 

Anatomy of breasts and lactation.393 

Nursing.396 

Care of breasts.398 

Artificial feeding.400 

XVIII. Multiple Pregnancy .402 

Frequency.402 

Etiology.402 

Relation of the placentae and membranes .... 406 

Superfecundation and superfetation.409 

Diagnosis.411 

Course of labor.412 


xiii 

PAGE 

285 

285 

298 

304 























XIV 


CONTENTS 


SECTION V 


Obstetric Surgery 


CHAPTER 


PAGE 

XIX. 

Induction of Abortion and Premature Labor 

417 


Preparations for obstetrical operations 

417 


Induction of abortion. 

419 


Induction of premature labor. 

424 


Accouchement force. 

431 


Vaginal cesarean section. 

434 

XX. 

Forceps . 

439 


History. 

440 


Functions. 

444 


Indications. 

444 


Preparations for operation. 

447 


Application of forceps. 

448 


Low and mid forceps operations. 

455 


Application of forceps in obliquely posterior presentations 459 


Application of high forceps. 

463 


Axis traction forceps. 

463 


Application of forceps in face presentations 

466 


Application of forceps in breech presentations 

. 467 


Prognosis. 

467 

XXI. 

Extraction and Version. 

471 


Extraction in breech presentations .... 

471 


Cephalic version. 

483 


Podalic version. 

485 


Combined podalic version. 

491 

XXII. 

Cesarean Section, Symphyseotomy, and Pubiotomy 

493 


History. 

493 


Indications. 

496 


Operative technic. 

499 


Prognosis. 

511 


Symphyseotomy . 

517 


Pubiotomy. 

518 

XXIII. 

Destructive Operations. 

527 


Craniotomy. 

527 


Embryotomy. 

533 


Evisceration. 

533 


Decapitation.; 

533 

XXIV. 

Operative Procedures Which Do Not Aim at Delivery 

537 


Douche . 

537 


Curettage. 

539 


Tampon or pack. 

541 


Manual removal of placenta. 

543 































CONTENTS xv 

SECTION VI 
Pathology gv Pregnancy 

CHAPTER page 

XXV. Accidental Complications of Pregnancy Due to Disease . 545 

Acute infectious diseases.545 

Chronic infectious diseases.549 

Diseases of circulatory and respiratory systems . . . 554 

Diseases of alimentary tract and liver.559 

Diseases of kidneys and urinary tract.561 

Diseases of the nervous system.565 

Diseases of blood.568 

Diseases of skin.569 

| Surgical operations during pregnancy.571 

XXVI. The Toxemias of Pregnancy.577 

Pernicious vomiting of pregnancy.578 

Acute yellow atrophy of liver.587 

Nephritic toxemia.590 

Pre-eclamptic toxemia.593 

Eclampsia.597 

Presumable toxemias.628 

XXVII. Complications Due to Diseases and Abnormalities of the 

Generative Tract.637 

Diseases of vulva and vagina.637 

Diseases of the cervix.638 

Developmental abnormalities of uterus.639 

Displacements of uterus.642 

Hypertrophic elongation of the cervix.648 

Acute edema of the cervix.649 

Hernia.649 

Diseases of decidua.650 

1 XXVIII. Diseases and Abnormalities of Ovum.656 

Diseases of chorion.656 

Chorio-epithelioma.662 

Diseases of amnion.667 

Abnormalities of placenta.673 

Diseases of placenta.677 

Abnormalities of umbilical cord.683 

Disease of the foetus.686 

XXIX. Abortion, Miscarriage, and Premature Labor . . . 701 


XXX. Extra-utertne Pregnancy 


719 




























XVI 


CONTENTS 


SECTION VII 


Pathology of Labor 

CHAPTER 

XXXI. Dystocia Due to Anomalies of Expulsive Forces 

Prolonged labor. 

Precipitate labor. 

Tetanic contraction of uterus. 

Dystocia clue to contraction of Bandl’s ring 

Hour-glass contraction of uterus. 

Missed labor. 

XXXII. Dystocia Due to Abnormalities of Generative Tract 

Atresia of vulva. 

Atresia of vagina. 

Stenosis and rigidity of cervix. 

Dystocia due to uterine displacements. 

Dystocia due to operations for the relief of retroflexion of 

the uterus . 

Dystocia due to tumors of generative tract and pelvis 


XXXIII. Contracted Pelvis . 

History 

Frequency 

Methods of diagnosis 
Pelvimetry . 
Classification 


XXXIV. Anomalies Due to Abnormal Malleability of Pelvic 

Bones . 

Flat, non-rhachitic pelvis. 

Rhachitic pelvis. 

Forms of rhachitic pelves. 

Diagnosis of rhachitic pelvis. 

Mode of production of the rhachitic deformities 
Osteomalacic pelves. 


XXXV. Abnormal Pelves Resulting from Primary Anomalies of 

Development. 

Generally enlarged (justomajor) pelvis 
Generally contracted (justominor) pelvis 

Masculine pelvis. 

Infantile pelvis. 

Dwarf pelvis. 

Obliquely contracted or Naegele pelvis 
Transversely contracted or Robert pelvis 

Split pelvis. 

Imperfect development of the vertebral bodies of the 

sacrum. 

Assimilation pelvis. 

Funnel pelvis. 



























CONTENTS 


XVJl 


CHAPTER PAGE 

XXXVI. Course, Prognosis and Treatment of Pregnancy and Labor 

Complicated by the More Common Forms of Con¬ 
tracted Pelvis.847 

Effect of contracted pelvis upon the course of pregnancy 847 

The position of the uterus.847 

Position and presentation of foetus.847 

Size of foetus.848 

Mechanism of labor in rhachitic pelves .... 848 

Course of labor in contracted pelvis.853 

Treatment of labor complicated by contracted pelvis . . 860 

Treatment of labor complicated by osteomalacic pelves 870 


XXXVII. Pelvic Anomalies Due to Disease of the Vertebral 

Column.874 

Kyphotic pelvis.874 

Kyphorhachitic pelvis.881 

Scoliotic pelvis.881 

Kyphoscoliotic pelvis.883 

Kyphoscoliorhachitic pelvis.884 

Spondylolisthetic pelvis.884 

XXXVIII. Pelvic Anomalies Resulting from Abnormal Direction of 

the Force Exerted by the Femora .... 892 

Coxalgic pelvis.892 

Coxarthrolisthetic pelvis.896 

Pelvic deformity due to bilateral lameness .... 896 

Atypical deformities of pelvis.898 

XXXIX. Dystocia Due to Abnormalities in Development or Pres¬ 
entation of Fcetus.900 

Excessive development.900 

Malformation of fcetus.902 

Deformities of fcetus.903 

Hydrocephalus 904 

Enlargement of the body of fcetus.906 

Transverse presentations.909 

Compound presentations.917 

XL. Hemorrhage..920 

Premature separation of the normally implanted placenta 920 

Placenta previa.927 

Postpartum hemorrhage.938 

Inversion of uterus.944 

XLI. Injuries to Birth Canal.950 

Injuries to vulval outlet.950 

Injuries to vagina.950 

Lesions of cervix.952 

Rupture of uterus.955 

Instrumental performation of uterus ..... 962 

Perforation of genital tract following necrosis . . . 963 































CHAPTER 

XLII. Prolapse of Umbilical Cord, etc. 

Asphyxia. 

Sudden death during or shortly after labor . 


SECTION V in 
Pathology of the Puerperium 

XLIII. Puerperal Infection. 

XLIV. Diseases and Abnormalities of the Puerperium 

Tetanus. 

Thrombosis of vessels of lower extremities . 
Gangrene of the extremities .... 

Diseases of urinary tract. 

Hemorrhages during puerperium . 

Diseases and abnormalities of uterus . 
Delayed chloroform poisoning .... 

Obstetrical paralysis. 

Abnormalities and diseases of breasts . 

Puerperal psychoses. 

Acute infectious diseases during puerperium 


Index 









LIST OF PLATES 


facing 

PAGE 


PLATE 

I. 

II. 

III. 

IV. 
IV, A. 

IV, B. 
V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 
XV. 

XVI. 

XVII. 


Frozen section through woman dying at beginning of second 
stage of labor; breech presentation .... Frontispiece 

Showing several varieties of hymen.. 

Section through endometrium on third day of menstruation 

Peters’ ovum. 

Diagram illustrating changes in the fertilized ovum during the 

process of imbedding. 

Diagram showing mature ovum and its changes after fertilization 

Section through four months’ placenta, showing junction of 

chorion and decidua • 

Terminal chorionic villus with injected vessels • 

Corrosion preparation of mature placenta, to show foetal vessels 

Foetal circulation. 

Seven and a half months’ pregnant uterus from woman dying 

in first stage of labor. 

Palpation in left occipito-anterior presentation .... 
Palpation in right occipitoposterior presentation 
Palpation in right mento-anterior presentation 
Palpation in left sacro anterior presentation .... 

Placental infarct formation .... 

Palpation in right acromiodorso-anterior presentation . 

Hemorrhagic changes in uterus associated with premature sepa- 

ration of placenta.. ’ . . „ , • 

Section through endometrium in streptococcic puerperal infection 


32 

86 

112 

114 

114 

142 

144 

146 

168 

270 

288 

300 

308 

318 

678 

910 

924 

990 


xix 



OBSTETRICS 


SECTION I 


ANATOMY 


CHAPTER I 
THE PELVIS 

Historical. —As the mechanism of labor is essentially a process of 
accommodation between the foetus and the passage through which it 
must pass, it is apparent that obstetrics lacked a scientific foundation 
until the anatomy of the bony pelvis and of the soft parts connected 
with it was clearly understood. 

We are indebted to Andreas Yesalius (1543) for the first accurate 
description of the pelvis. Prior to the publication of his observations it 
had generally been believed that the birth of the child could not be 
effected until the pelvic cavity had become increased in size by the 
separation and gaping of the pelvic bones. Yesalius demonstrated the 
fallacy of this conception, and showed that the pelvis, lor practical pur¬ 
poses, should be considered as an unyielding bony ring. His work was 
further elaborated by his successor at the University of Padua, Realdus 
Columbus, who also demonstrated that each innominate bone was 
originally composed of three separate portions: the ilium, ischium, and 
pubis, which fused together just before the age of puberty. Julius 
Caesar Arantius, Professor of Anatomy in Bologna (1559), also made 
important contributions to the subject, and was the first lo recognize the 
existence of contracted pelvis. 

That the teachings of these three great anatomists did not exert so 
great an influence as might have been expected was largely due to the 
fact that no less an authority than Ambroise Pare still continued to 
adhere to the doctrine of the separation of the pubic bones during labor, 
and promulgated it in his obstetrical writings. 

Among obstetricians, Heinrich van Deventer was the first to make 
a thorough study of the anatomy of the pelvis. In his New Light for 
Mid-wives (1701) he dwelt upon it in detail, and also described the mam 
varieties of contracted pelves. At that time he felt called upon to apolo¬ 
gize for taking up what was apparently so useless a consideration. 

1 


2 


THE PELVIS 


Smellie was the first English authority to devote particular attention 
to the subject. In his work on midwifery, published in he ga\e 

an accurate description of the pelvis and its various measurements, and 
also introduced the method of determining the anteroposterior diameter 
which we still employ. A few years previously (1735), Johann Huwe 
had gone over somewhat the same ground, but his work did not leceive 
anything like the consideration which was accorded to Smellie’s investi¬ 
gations. 

Almost simultaneously with Smellie, Levret, the great French obste¬ 
trician, published the results of his observations, and was one of the first 
to promulgate the conception of the axis and the planes ol the pel\is. 
The value of his work, however, was considerably impaired by many 



inaccuracies. Among the Germans, Stein the younger was apparently 
the first to give a thoroughly accurate description of the pelvis, and since 
his time correct ideas upon the subject have gradually become popu¬ 
larized. Practically, therefore, an attempt to follow the further develop¬ 
ment of our knowledge concerning the pelvis would resolve itself into 
writing a history of obstetrics. To do this would go far beyond the 
scope of the present work; and let it here' suffice to say that among the 
more modern authors Naegele, Luschka, Michaelis, Litzmann, and Breus 
and Kolisko in Germany, and Hodge in this country deserve particular 
mention. 

General Considerations.—In both sexes the pelvis forms the bony 
ring through which the body weight is transmitted to the lower extremi¬ 
ties, but in the female it assumes a peculiar form which adapts it to the 
purposes of childbearing. 

Tt is composed of four bones: the sacrum, the coccyx, and two in¬ 
nominate bones, the last two being united by strong articulations with 
the sacrum at the sacro-iliac synchondroses, and with one another at the 
symphysis pubis. The purely anatomical characteristics of the pelvis 




THE PELVIS FROM AN OBSTETRICAL POINT OF VIEW 


3 


e 


are dealt with at length in the standard works on anatomy, so that we 
shall limit our considerations to the peculiarities of the female pelvis 
which are of importance in childbearing. 

The Pelvis from an Obstetrical Point of View.—The linea terminalis 
( forms the boundary between the false and the true pelvis, the former 
lying above and the latter below it. The false pelvis is bounded pos¬ 
teriorly by the lumbar vertebrae and laterally by the iliac fossae, while in 
front the boundary is formed by the lower portion of the anterior ab¬ 
dominal wall. It possesses no particular obstetrical significance, but 
serves to support the intestines in the non-pregnant woman, and the 
enlarged uterus in the pregnant condition. It varies considerably in 
size in different individuals, according to the flare of the iliac bones; 
but ordinarily in dried specimens the distances between the anterior 
superior spines of the ilium and between the most widely separated 
portions of the iliac crests measure 23 and 2(1 centimeters, respectively. 

The true pelvis lies beneath the linea terminalis, and is the portion 
concerned in childbearing. It is bounded above by the promontory and 
alae of the sacrum, the linea terminalis, and the upper margins of the 
pubic bones, and below by the pelvic outlet. Its cavity, roughly speaking, 
may be compared to an obliquely truncated cylinder with its greatest 
height posteriorly, since its anterior wall at the symphysis pubis meas¬ 
ures 4.5 to 5 centimeters, and its posterior wall 10 centimeters. With 
the woman in the upright position, the upper portion of the pelvic canal 
is directed downward and backward, while in its lower course it curves 
and becomes directed downward and forward. 

The walls of the true pelvis are partly bony and partly ligamentous. 
Its posterior boundary is furnished by the anterior surface of the sacrum, 
its lateral limits are formed by the inner surface of the ischial bones and 
by the sacrosciatic notches and ligaments; while in front it is bounded 
by the obturator foramina, the pubic bones, and the ascending rami of 
the ischial bones. 

The only part of the lateral wall of the pelvis which is entirely bony 
is made up of the body of the ischium and part of the ilium, the inner 
surface of which, with the woman in the upright position, forms an in¬ 
clined plane which is directed from above downward and inward, and 
from behind forward. These surfaces were designated as the inclined 
planes of the pelvis by Hodge, who taught that they exercised consider¬ 
able influence in causing internal rotation of the head during labor. 
This view, however, has since been abandoned. If the planes of the 
ischial bones were extended downward they would meet somewhere about 
the region of the knee. Extending from the middle of the posterior 
margin of each ischium are the ischial spines, which are of no little 
obstetrical importance, inasmuch as a line drawn between them represents 
the shortest diameter of the pelvic cavity. Moreover, since they can be 
readily felt on vaginal examination, they serve as valuable landmarks in 
determining the extent to which the presenting part has descended into 
the pelvis. 

The sacrum; forms the posterior wall of the pelvic cavity. Its upper 
anterior margin, corresponding to the body of the first sacral vertebra, 





4 


THE PELVIS 


and designated as the promontory, can be felt on vaginal examination, 
and offers a landmark which serves as the basis of internal pelvimetry. 
Normally, the sacrum presents a marked vertical and a less pronounced 

lateral concavity, which, 
in abnormal pelves, may 
undergo variations. A 
straight line draw n 
from the promontory to 
the tip of the sacrum 
usually measures 10 
centimeters, whereas if 
the concavity be fol¬ 
lowed the distance aver¬ 
ages 12 centimeters. 
The sacrum was form¬ 
erly regarded as the 
“keystone” of the pelvic 
arch, but Matthews 

Duncan showed that 

Fig. 2.—Drawing showing that the Sacrum is not this conception was er- 
the Keystone of the Arch. Modified from Dun- 1 * .. 

can. x y 3 . roneous, and that it 

represents an inverted 

keystone, inasmuch as it is wider along its anterior than along its pos¬ 
terior surface, so that it would tend to slip downward and forward into 
the pelvic cavity un¬ 
der the influence of 
the body weight were 
it not held in posi¬ 
tion by the strong 
posterior iliosacral 
ligaments (Fig. 2). 

In the female the 
pubic arch presents 
a characteristic ap¬ 
pearance. The de¬ 
scending rami of the | 
pubis unite at an \ 
angle of 90 to 100 \ 
degrees, and form a 
r o u n d e d opening 
through which the 
head can readily 
pass. Its margins 
are more delicate 

than in the male, FlG ' 3 -~ Sagittal Section through Normal Pelvis. X J 
and are considerably everted. 

Planes and Diameters of the Pelvis.—Owing to the peculiar shape of 
the pelvic cavity and the difficulty experienced in rendering clear the 
exact location of a body occupying it, for greater convenience in de- 
















PLANES AND DIAMETERS OF THE PELVIS 5 

' scription it is customary to construct certain imaginary planes through 
j it. Those most frequently employed are designated as (1) the superior 
strait; (2) the inferior strait; (3) the plane of greatest, and (4) the 
plane of least, pelvic dimensions (Figs. 3 and 5). 

^ The _superior strai t represents the upper boundary of the cavity, and 
is frequently spoken of as the pelvic inlet. It is somewhat oval in shape, 
with a depression on its posterior border corresponding to the promontory 
of the sacrum, and is sometimes described as blunt heart-shaped. It is 
! bounded posteriorly by the promontory and alae of the sacrum; laterally 
I by the linea terminalis; anteriorly by the horizontal rami of the pubic 
bones and the upper margin of the symphysis pubis. Strictly speaking, 
it is not a mathematical plane, since its lateral margins, as represented 



Fig. 4.—Normal Female Pelvis showing Diameters of the Superior Strait. X l A 


by the linea terminalis, are at a lower level than its central portion 
between the promontory and symphysis. 

Four diameters are usually described as traversing the superior 
strait: the anteroposterior, the transverse, and two oblique diameters. 
The anteroposterior diameter extends from the middle of the promontory 
of the sacrum to the upper margin of the symphysis pubis, and is desig¬ 
nated as the conjugata vera or true conjugate. This term was first em¬ 
ployed by Roederer, who likened the superior strait to an ellipse, whose 
shorter diameter ran anteroposteriorly. Normally, the conjugata vera 
measures 11 centimeters, but it may become markedly shortened in ab¬ 
normal pelves. From a practical point of view it is the most important 
diameter, inasmuch as it is the point of departure for all attempts to 
estimate the size of the pelvis in actual practice. The transverse 
diameter is constructed at right angles to the conjugata vera, and repre¬ 
sents the greatest distance between the linea terminalis on either side; 
it usually intersects the conjugata vera at a point a short distance in 
front of the promontory. Normally it measure s 13.5 c entimeters. Each 
of the oblique diameters extends from one of the sacro-iliac svnchon- 



















6 


THE PELVIS 




droses to the iliopectineal eminence on the opposite side of the pelvis. 
They measure 12.75 centimeters, and are designated as right and left 
respectively, according as the starting-point is the right or left sacro¬ 
iliac synchondrosis. Instead of employing these terms, the Germans 
usually speak of the first and second oblique diameters, respectively. The 


Fig. 5.—Diagram showing Pelvic Planes. X } i - 


sacrocotyloid diameters are sometimes described; they extend from the 
middle of the promontory of the sacrum to the iliopectineal eminence 
on either side, and measure from 8.75 to 9 centimeters. Normally these 
two diameters are of equal length, but in certain forms of contracted 
pelvis they may present marked variations. 


The anteroposterior diameter of the superior strait, or conjugata vera, 
is also designated as the anatomical con jugate. This does not represent 
I lie shortest distance between the. .promontory of the sacrum and symphy¬ 
sis pubis, which is along a line drawn from the former to a point on the 


Fig. 0.—Pelvic Outlet. X 1 
















PLANES AND DIAMETERS OF THE PELVIS 


inner surface of the symphysis a fe w millim eters below its upper margin. 
The latter is the shortest diameteT through which the head must pass in 
descending into the superior strait, and was designated by Michaelis as 
the obstet rical co njugate. It is a few millimeters shorter than the 


Rectus 


_Symphysis 

i ‘ r ^or\r'ReCtus 



Pubis 

O S> c 0 • e \ 

< *, . «■ i v .e o i 

0 bturator ffW A 0 [iterator 

i oramen,^/' v'oramen 

Ilium"/f 



Promontory ^ a * S5=sas ^ S acrum 

Fig. 7. —Superior Strait (Veit). Fig. S. —Plane of Greatest Dimensions. 


anatomical or true conjugate, but for practical purposes the distinction 
is rarely made, and the obstetrician simply speaks of the conjugata vera. 

Unfortunately, in the living woman, the conjugata vera can not lie 
measured directly with the examining finger, and various more or less 

Pubic ramus 

Pubic ramus 


of Sacrum 

Fig. 9 —Plane of Least Dimensions (Veit). Fig. 10.— Veit’s Main Plane. 

complicated instruments have been devised for its determination, none 
of which gives perfectly satisfactory results. For clinical purposes, there¬ 
fore, we are content to es timate its length indirectly, by measuring the 
distance .f rom the lower margin of the symphysis to the promontory of 
the sacrum, and subtracting from the result Lfi-to.,,2, centimeters, ac¬ 
cording to the height and inclination of the symphysis pubis. This 
























8 


THE PELVIS 


diameter is the conjugaia diagonalis or oblique conjugate, the impor¬ 
tance of which was first emphasized by Smellie. 

The outlet of the pelvis is designated the inferior strait. It is not 
a plane in a mathematical sense, but consists of two triangular planes 
whose bases would meet on a line drawn between the two ischial tuber¬ 
osities. It is bounded posteriorly by the tip of the coccyx, laterally by 
the greater sacrosciatic ligaments and the ischial tuberosities, and an¬ 
teriorly by the lower margin of the pubic arch (Fig. G). For the pelvic 
outlet two diameters are described: the anteroposterior and the trails- j 
yerse. The former extends from the lower margin of the symphysis 
pubis to the tip of the coccyx, and the latter between the inner margins 
of the ischial tuberosities. With the coccyx in its usual position, the 
anteroposterior diameter measures JL5. centimeters, which is increased 
to 11.5 centimeters during labor by the backward displacement of the tip 
of the coccyx. The transverse diameter measures 11 ^centimeters. 

The plane of greatest pelvic dimensions was first described by Levret, 
and, as its name implies, represents the roomiest portion of the pelvic 
cavity. It extends from the middle of the posterior surface of the sym¬ 
physis pubis to the junction of the second and third sacral vertebrae, i 
and laterally passes through the ischial bones over the middle of the ace¬ 
tabulum. Its anteroposterior and transverse diameters measure 12.75 
and 12.5 centimeters, respectively. Since its oblique diameters terminate 
in the obturator foramina and the sacrosciatic notches, their length is 
indeterminate. 

The plane of least pelvic dimensions extends through the lower mar¬ 
gin of the s ymphysis pubis, the tip of the sacrum, and the ischial spines. 
Its anteroposterior diameter measures LLiLcnn Its transverse diameter 
extends between the ischial spines and measures l(k5 centimeters, being 
the shortest diameter in the normal pelvic cavity. 

In order to facilitate the study of the pelvic cavity, Hodge con¬ 
structed four parallel planes, the first of which is the superior strait; 
while the other three are parallel to it and pass through the lower margin 
of the symphysis pubis, the ischial spines, and the tip of the coccyx 
respectively. The second parallel practically corresponds to the plane 
of greatest pelvic dimensions, and is very closely related to that described 
by Veit as the main plane of the pelvis, which extends from the lower 
margin of the symphysis pubis to the junction of the first and second 
sacral vertebrae. According to Veit this, from an obstetrical standpoint, 
is the largest plane of the pelvis, inasmuch as it is not encroached upon 
by the pelvic soft parts, but passes above the obturator and pvriformis 
and below the iliopsoas muscles. 

Most pelves present slight individual variations in size, and perfectly 
normal and symmetrical examples are rarely seen. The measurements 
which we have given are those of Schroeder, and are the averages obtained 
from the accurate mensuration of 50 normal pelves. 

Pelvic Inclination. —The normal position of the pelvis, with the 
woman in the erect posture, can be reproduced by holding the specimen 
in such a way that the incisions of the acetabula look directly downward. 
According to Meyer, the same result is obtained when the anterior- 









PELVIC INCLINATION 


9 


superior spines of the ilium and the pubic spines are placed in the same 
vertical plane. Under these conditions the promontory of the sacrum 
is 9.5 to 10 centimeters higher than the upper margin of the symphysis 
pubis. 

By the term pelvic inclination is understood the angle which the 
plane of the superior strait forms with the horizon (see Fig. 3). This 
conception was first introduced by J. J. Muller and Roederer, and the 
early statements concerning it were very conflicting. According to 
Meyer, the center of gravity of the body passes along an imaginary 
vertical plane just posterior to the acetabula, so that under the influence 
of the body weight the pelvis would tend to rotate backward, were it not 
held in position by the strong iliofemoral ligaments. It is therefore 
apparent that the pelvic inclination must vary according to the degree of 
tension of these structures; it will be diminished when they are relaxed, 
and vice versa. It is least marked when the legs are slightly rotated 
inward and spread a little apart, and greatly increased when the knees 
are pressed tightly together, or when the legs are widely spread apart or 
rotated strongly either inward or outward. With the woman in the up¬ 
right position the pelvic inclination is usually estimated at 45 to 50 
degrees, but may vary from 40 to 100 degrees, according to the degree of 
tension exerted by the iliofemoral ligaments. In certain diseased con¬ 
ditions it may be obliterated, when the plane of the superior strait may 
become parallel to, or even form an obtuse angle with, the horizon. 

The first accurate work upon this subject was done by Naegele, who 
measured the distance from the floor to the lower margin of the sym¬ 
physis pubis and the tip of the sacrum respectively, and in this way esti¬ 
mated the inclination which the inferior strait formed with the horizon. 
He then placed a normal pelvis in a similar position and estimated the 
inclination of its superior strait, which was usually about 60 degrees. 

In view of the variations to which the pelvic inclination is subject, 
Meyer introduced a new conception concerning it, and showed that it 
was considerably influenced by the extent to which the sacrum rotated 
about its transverse axis. As this passes through the center of the body 
of the third sacral vertebra, it is apparent that this portion of the 
sacrum retains approximately the same position, no matter to what ex¬ 
tent its upper or lower portions may be displaced. Meyer, therefore, 
constructed a diameter extending from the upper margin of the symphy¬ 
sis to the middle of the third sacral vertebra, and designated it the normal 
conjugate. Its inclination he estimated at 30 degrees, and stated that it 
remains practically constant in all positions of the body. 

Except when markedly abnormal, the pelvic inclination posseses no 
practical obstetrical significance, and is of value only in the study of 
atypical pelves and in anthropology. Several complicated instruments 
have been invented for determining it. In 1900, Neumann and Ehrenfest 
pointed out that for practical purposes the degree of pelvic inclination 
corresponds to the inclination of the external conjugate, and devised a 
comparatively simple instrument for determining it. 

Since the lower margin of the symphysis occupies a lower level than 
the tip of the sacrum, the plane of the inferior strait is also inclined to 









10 


THE PELVIS 


the horizon, forming an acute angle, which is usually estimated at 10 
degrees. Much more important, however, is the angle which is formed 
between the posterior surface of the symphysis pubis and the conjugata 
A r era; this is usually estimated at 90 to 100 degrees, but varies consid¬ 
erably according to the shape, height, and inclination of the former. 
This must always be taken into consideration in estimating the length 
of the conjugata vera from that of the conjugata diagonalis, since it is 
evident that the amount to be subtracted from the latter will vary with 
the size of the angle in question. 

The Pelvic Axis. —Deventer in 1701 introduced the conception of a 
pelvic axis. Since then numerous methods for its construction have been 
described, the most usual being a line drawn through the centers of in¬ 
numerable planes extending from the symphysis to the sacrum, thus 



giving a graceful curve (see Fig. 3). This was formerly believed to 
represent the course which the child pursued in its passage through the 
pelvis, but the work of Naegele, Hegar, Pinard, and others has shown 
that such is not the case, and that an axis so constructed possesses only 
an historical interest. 

At the end of pregnancy the axis of the superior strait, if extended 
diiectly upward, would pass through the abdominal Avail at about the 
region of the umbilicus, Avhile the axis of the inferior strait Avould im¬ 
pinge upon the promontory of the sacrum. As the pelvic canal is prac¬ 
tically cylindrical in shape down to the plane of greatest pelvic dimen¬ 
sions, it is appaicnt lhat the head must descend along the doAAmward 
prolongation of the axis of the superior strait until it has nearly reached 
the level of the ischial spines, and only begins to curve forward in the 
region of the inferior strait. Therefore the obstetrical pelvic axis should 
be represented as straight in its upper and curved only in its lower 
portion (see Fig. 11), as was well understood by Hodge, and stronglv 
insisted upon by Sellheim. 




















THE PELVIC JOINTS 


11 




The Pelvic Joints. Anteriorly the pelvic bones Are held together by 
he symphysis pubis, which consists of a mass of fibrocartilage, and by 
he superior and inferior pubic ligaments, the latter being frequently 
lesignated as the ligamentum arcuatum pubis. Luschka demonstrated 
he presence of a synovial cavity in the fibrocartilage, and therefore 
dassed the symphysis among the true joints (Fig. 12). Joessel, and 
Loeschke, on the other hand, deny its existence, and state that the fluid 
in the interior of the symphysis is simply a product of degeneration. 
Whether it be a true joint or not, in any case the symphysis admits of 
i certain amount of motility, which becomes more marked during preg¬ 
nancy, particularly in multiparous women. This fact was demonstrated 
by Budin, who showed that if the finger were inserted into the vagina of 



Fig. 12.—Frontal Section Symphysis Fig. 13.—Sacro-iliac Synchondrosis 
Pubis (Spalteholz). X 1. (Spalteholz). X 1. 


a pregnant woman, and she were made to walk, one could distinctly feel 
the ends of the pubic bones move up and down with each step. 

The articulations between the sacrum and innominate bones were 
formerly described as synchondroses, but Luschka conclusively demon¬ 
strated the presence of a synovial cavity within them, and therefore 
classed them among the true joints (Fig. 13). These articulations pos¬ 
sess a certain amount of motility, which plays a not unimportant part in 
practical obstetrics. 

Walcher, in 1889, redirected attention to the variation in size of 
different portions of the pelvic canal resulting from changes in the 
relation between the thighs and the pelvis, and stated that the diagonal 
conjugate varied about 1 centimeter in length, according as it was meas¬ 
ured with the woman in the usual obstetrical position, or with her 
buttocks resting on the edge of the table and her legs hanging down 
without any support. This has since been known as the Walcher or 
hanging position, and is utilized in dealing with contracted pelves; and 
occasionally the increase in the size of the conjugata vera brought about 
by it has proved sufficient to permit the engagement of the presenting 
part, which otherwise could not occur. Kiittner in 1898 showed in three 











12 


THE PELVIS 


cases that the conjugata vera was respectively 1.4, 0.9, and 1 centimeter 
longer when measured in the hanging than in the lithotomy position. 
Fig. 14 gives a graphic illustration of the changes in shape in one of the 
pelves, which he studied. 

Furthermore, rotation of the innominate bones upon the sacrum 
causes changes in the anteroposterior diameter of the infeiior strait. I® 

the Walcher position it is shorty 
ened, whereas it is lengthened 
when the legs are sharply flexed 
over the body. In 1911, I 
showed that it could also be in¬ 
creased by from 1 to 2.5 centi¬ 
meters by placing the woman in 
an exaggerated Sims position. 

Methods of Comparing 
Pelves.—Inasmuch as the nor¬ 
mal pelvis usually presents 
slight individual variations in 
its form and dimensions, and 
as contracted pelves differ mark¬ 
edly from one another in shape, 
several devices have been em¬ 
ployed to enable us readily to 
compare their points of difference. The decimal method, suggested by 
Litzmann, is very satisfactory for most purposes. In it the various 
diameters are expressed in terms of the conjugata vera, which is 
reckoned as 100. 



Fig. 14. —Diagram showing Variation of 
Anteroposterior Diameter of Pelvis 
in Various Positions (Kiittner). X Vs- 

A, lithotomy; B, horizontal; C, Walcher’s 
position. 


Comparison of Various Diameters 
of Normal Pelves by Litzmann’s 
Decimal Method. 

diameters. 

Anteroposterior. 

Transverse. 

Oblique. 

Superior strait. 

100 

122.7 

113 

Plane of greatest pelvic dimension. 

115 

113.6 


Plane of least pelvic dimension. 

105.5 

95.5 


Inferior strait. 

105.5 

100 



Breisky introduced a graphic method for comparing pelves and con¬ 
structed three diagrams, representing a vertical mesial section of the 
pelvis, the plane of the superior strait, and a frontal view of the pelvis. 
The first is constructed upon Meyer’s normal conjugate, the second upon 
the distance between the sacro-iliac synchondroses, and the third upon 
the transverse diameter of the pelvic outlet (Figs. 15-17). 

Individual Variations in the Pelvis.—With the exception of the skull, 
no portion of the skeleton presents greater individual variations than the 
pelvis. This is due partly to the fact that it is developed from a consid¬ 
erable number of bones, and partly to the varying mechanical and devel¬ 
opmental influences to which it is subjected during the early years of 
life. Indeed, we may say that no two pelves are exactly alike, and that 
perfectly normal pelves are rarely seen; so that an accurate conception 
of the form and dimensions of what may he termed the normal type can 


























13 


SEXUAL DIFFERENCES IN THE ADULT PELVIS 

be obtained only from averages based upon the examination of numerous 
approximately normal pelves. 

Owing to the greater employment of tlie right half of the body, the 
corresponding side of the pelvis is more developed than the left. Indi¬ 
vidual variations may be observed in the form, consistence, and general 
chaiacter of the pel\ic bones, in the angles which the iliac fossae form 
v ith the w alls of the pelvic basin, in the shape of the sacrum, and par¬ 
ticularly in that of the cavity itself. In view of the varying thickness of 
the pelvic bones, and especially of the degree of flaring of the ilia, ac¬ 
curate conclusions cannot be drawn from external pelvimetry alone. 



Figs. 15-17.— Breisky’s Diagrams for Comparing Telves. 

/., inclination of iliac bones; I. P., iliopectineal eminence; P., promontory of sacrum; S., 
upper margin of symphysis; S. 1 , lower margin of symphysis; S. sacro-iliac synchon¬ 
drosis; Sp., iliac spines; T., transverse diameter, superior strait; T. tuber ischii; 3, 
bend in body of third sacral vertebra. 

Sexual Differences in the Adult Pelvis. —The pelvis presents marked 
sexual differences. Speaking generally, we may say that in the male the 
pelvis is heavier, higher, less graceful, and presents a more conical ap¬ 
pearance than in the female. In the former the muscular attachments 
are much more strongly marked, and the iliac bones are less flared than 
in the latter. The pubic arch is more angular in shape, and presents an 
aperture of 70 to 75 degrees, as compared to 90 to 100 degrees in the 
female. This difference is so marked that one usually speaks of the 
pubic angle in the male and the pubic arch in the female. In the male 
pelvis the superior strait is smaller and more triangular in outline, 
vhile the pelvic cavity is deeper and more conical in shape. These dif- 
r ences are readily noted in Figs. 18, 19, and 20, and may be especially 
hasized by a comparison of the various measurements in the two 

>adly speaking, the external measurements are practically alike in 
es, though the distance between the anterior-superior spines of 
i is somewhat less in the male; while all the diameters of the 









14 


TIIE PELVIS 




pelvic cavity are shorter, as is shown by the table on page 15. Indeed, 
the outlet of the male type of pelvis is contracted to such a degree as to 
render very difficult the passage of a living child under the pubic angle. 


Fig. 18. —Front View Female Pelvis. X ^3. 

Occasionally the female pelvis may approach the male type, and such 
funnel pelves may offer insuperable obstacles to the birth of the child, 
and necessitate radical operative procedures to effect delivery. 


Fig. 19.—Front View Male Pelvis. X 

Numerous not very satisfactory attempts have been made J 
the cause of the differences between the male and female pelvis 
ing to Fehling and most subsequent investigators, sexual 
make their appearance as early as the fourth or fifth mor 





SEXUAL DIFFERENCES IN THE ADULT PELVIS 


15 


uterine life, so that the sex can be ascertained long before term by ex¬ 
amination of the pelvis. Arthur Thompson has made the same state¬ 
ment, and my own investigations have led me to similar conclusions. On 
the other hand, Schroeder and other authorities attributed the charac¬ 
teristic shape of the female pelvis to the presence of the internal 
genitalia, and stated that the pelves of female eunuchs, as well as those of 
individuals in whom the uterus is congenitally absent, conform to the 


Comparison of Male and Female 
Pelvis. 

Anteroposterior. 

DIAMETERS. 

Transverse. 

Oblique. 

Superior strait: 




Male. 

10.5 

12.5 

12 cm 

Female. 

11 

13.5 

12.75 cm. 

Inferior strait: 




M ale. 

9.5 

8 cm. 


F emale. 

11.5 

11 cm. 




Diagram showing Difference in Shape of Male [. . .] and Female [ ] 

Pelvis. 































1G 


THE PELVIS 


male type. While the correctness of such statements cannot be doubted, 
it nevertheless seems probable that the greater part of the sexual dif¬ 
ferences must be due to inherent developmental and hereditaiy factors. 

Racial Differences in Pelves.—Considerable variations may be ob¬ 
served in the form of the pelvis in various races, and especially upon 
comparing those obtained from aboriginal and civilized peoples. But in 
spite of the researches of Weber, Stein, Verneau, Topinard, Turner, and 
others, our knowledge of the subject is still fragmentary. Stein distin¬ 
guished four groups of pelves: 

1. Blunt heart-shaped. 

2. Elliptical, with the greatest diameter transverse. 

3. Round. 

4. Elliptical, with the greatest diameter anteroposterior. 

Topinard attempted to classify pelves according to their “general 

index”—that is, the relation between their height and width, as repre¬ 
sented by the distance between the iliac crests. His careful measurements 
showed that the pelves becomes increasingly lower and broader the more 
civilized the race from which it is obtained. 

Turner based his classification upon the relation between the trans¬ 
verse and anteroposterior diameters of the superior strait, and divided 
pelves into three great groups: dolichopellic, in which the conjugata 
vera is greater than the transverse diameter; mesatipellic, in which the 
conjugata vera and transverse diameters are of equal length; and platy- 
pellic, in which the conjugata vera is shorter than the transverse 
diameter. He stated that the first variety had not been observed in 
women, though it is not infrequent in men; but the investigations of 
Scharlau show that Turner was in error, as it is frequently noted in 
the aboriginal women of Australia. The mesatipellic variety is observed 
in the women of the lower races, notably among the Bushmen, Hotten¬ 
tots, and the lower classes of negroes ; while the platypellic forms are 
found in all the higher races. But even among civilized whites con¬ 
siderable racial differences are frequently noted, and it is generally 
stated that the pelves of the English and Holstein women are broader 
than those of other nationalities; while the Jewesses living in the 
vicinity of Dorpat have extremely small pelves. Gache states that 
the pelvis is usually normal in the Argentine Republic, while it is im¬ 
perfectly developed and frequently funnel-shaped in Mexico. 

While the study of the racial differences in the pelvis presents 
marked anthropological interest, it is, as yef, of little practical obstetr 
value, as no extended studies have been made concerning the forn 
size of the heads of children which are born through them. The 
work ot' my former assistant, 4'. F. Riggs, has shown that cc 
pelves occur several times more frequently among black tb 
women in Baltimore, while operative delivery is more freq 
quired among the latter. This is due to the fact that the neg) 
are somewhat smaller and have more compressible heads, am 
pensate for the smaller size of the pelvis. Acosta-Sison mal 
statement concerning the Philippine women, and Kinosb 
informs me that in Japan both the pelvic and cephalic 


PELVIS OF THE NEW-BORN CHILD 17 

fall below the average observed in European and American white women. 

Pelvis of the New-born Child.—The pelvis of the child at birth is 
Partly bony and partly cartilaginous. The innominate bone does not exist 
as such, its place being taken by the ilium, ischium, and pubis, which 
are united by a large Y-shaped cartilage, the three bones meeting in the 
acetabulum. The iliac crests and the acetabula, as well as the greater 
part of the ischiopubic rami, are entirely cartilaginous in structure. 
Figs. 21 and 22 clearly show the extent to which the infantile pelvis is 
ossified. 



The cartilaginous portions of the pelvis gradually give place to bone, 
but complete union in the neighborhood of the acetabulum does not occur 

until about the age of puberty, 
and occasionally even at a later 
period. Indeed, we may say that 




LOCKWOO 


Fig. 22.—Section through Infantile Pel¬ 
vis Parallel to Superior Strait, 
showing Relative Proportion of 
Bone and Cartilage. XI. 


Fig. 21.—Sagittal Section showing 
Relative Proportion of Bone and 
Cartilage in the Pelvis of a Newly 
Born Child. X 1. 


A., acetabulum; I., ilium; P., pubic bone; S., 
symphysis pubis; S. A., ala of sacrum: 
S. B., body of sacrum; V. A., vertebral 
arch. 


the innominate bones do not become completely ossified and fully de¬ 
veloped until between the twentieth and twenty-fifth years. 

Each innominate bone is developed from 12 centers of ossification. 
Three of these are primary and give rise to the ilium, ischium, and pubis. 
Vccording to Adair, they appear in the order named, and are all present 
V the nineteenth week of pregnancy. The remaining 9 centers—the 
called epiphyseal centers—are secondary, and do not develop until 
msiderably later period, some of them not until after the age of 

ty- 

3 sacrum at birth is likewise partly bony and partly cartilaginous, 
de up of 21 distinct bones, each of which is derived from a single 
ossification. The 21 centers are arranged as follows: 1 for each 
body (5) ; 3 for the alae on either side (6) ; and 2 for the 















18 


TIIE PELVIS 


arches of each vertebra (10). To these must be added the various 
epiphyseal centers which appear later. The cartilage gradually becomes 
ossified, and the various component parts of the sacrum fuse togethei 
The alae are the first portions to become united, after which the vertebra 
bodies gradually become welded together, the fusion extending from 
below upward. According to Litzmann, the bodies of the sacral verte¬ 
brae are not entirely united until the seventh year, and complete ossifica¬ 
tion of the sacrum is not effected until the twenty-fifth year. Fig. 23 
represents the disarticulated pelvis of a child three years old, and clearly 
shows the extent to which ossification has progressed at that age. 

The pelvis of the new-born child differs from that of the adult not 
only in being made up of a large number of bones, which are united by 
cartilage, but more particularly in its characteristic shape. This is 
clearly seen upon comparing Figs. 25 and 26, which represent vertical 
mesial sections through the trunk of a new-born child and of an adult 
woman. In the former the vertebral column is almost vertical, and its 
lumbar curvature practically absent. 

The promontory is very slightly 
marked, and is situated at a much 
higher level than in the adult. The 
sacrum is almost straight from above 







Fig. 23.—Disarticulated Pelvis of Three- 
year-old Girl. X M- 


Fig. 24. —Sagittal Section 
through Pelvis of Five- 
year-old Girl. X 


downward, but presents a more marked transverse concavity than in the 
adult. Its alae are only slightly developed, and as a consequence the 
pelvis is relatively narrower. The iliac fossae are almost vertical, and 
the horizontal rami of the pubis are far shorter than in the adult. Ttu 
pubic arch is much more angular, while the pelvic inclination is < 
cidedly greater. The superior strait is narrower and more angula 
shape, the relation between the eonjugata vera and the transvers 
ameter being 100 to 105, instead of 100 to 122.5, as in the adult, 
cavity of the pelvis is relatively much smaller, and is distinctly - 
shaped. The anteroposterior and transverse diameters of the peh 
let, when expressed in terms of the eonjugata vera, are respect 
and 73, instead of 104.5 and 100 as in the adult. 

As we have already indicated, sexual differences make thei 
ance at a very early period. Fehling showed that they could 1 
as early as the fourth month, when he found that the first sacr 
was wedge-shaped in the female, instead of cuboidal as in tin 




TRANSFORMATION OF FCETAL INTO ADULT PELVIS 


19 


results have since been confirmed by a number of observers, among whom 
Balandin, Jurgens, and Arthur Thompson may be mentioned: my own 
work also corroborates their statements. 


lo lecapitulate, the pelvis of the female foetus or new-born child 
presents the following characteristics as compared with that of the male 
The pelvic canal is less funnel-shaped, the pubic arch is wider, the sacro- 
sciatic notches are larger, and the lumbar region of the spinal column is 
more markedly curved. 

Transformation of Foetal into Adult Pelvis.—The mechanism by 
which the pelvis of the foetus is converted into the adult form is of in¬ 
terest, not only from a scientific, but also from a practical, point of view, 
as it affords important information concerning the mode of production 
of certain varieties of deformed pelves. 



Fig. 25.—Sagittal Section through Body Fig. 26.—Sagittal Section through Adult 
of Newly Born Child. Woman (Kelly), reduced to the Same 

Size as Fig. 25 for Comparison. 


The earliest investigations upon this subject were made by De Frem- 
ery, and Denman, who were followed by Litzmann, Duncan, Fehling, 
Schroeder, Veit, Yon Meyer, and others. At present it is generally be- 
<eved that in the evolution of the form of the pelvis two sets of factors— 
welopment and inherent tendencies, and mechanical influences—are 
cerned. That the process is not entirely the result of the action of 
'anical forces is manifested by the existence of sexual and racial 
mces in the adult pelvis, but especially by the presence of the 
in the foetal pelvis, long before it has been subjected to the 
echanical influences. On the other hand, the mechanical in- 
vhich come into play after birth are identical in both sexes. 



















20 


THE PELVIS 


but despite this fact the sexual differences become still further accen¬ 
tuated as puberty is approached. 

The part played by developmental and hereditary influences was 
clearly demonstrated by Litzmann, who showed that the female sacrum 
was characterized by a marked increase in width as compared w r ith that 
of the male. At birth, in both sexes, the body of the first sacral vertebrae 
is twice as broad as the alae (100 to 50), but in the adult the relation 
becomes 100 to 76 in the female, and 100 to 56 in the male, indicating 
a much more rapid growth of the alae in the former. Falk, in 1908, held 
that all the changes in the developing pelvis are due to similar causes, 
and that the influence of the various mechanical factors is merely ac¬ 
cessory. 

The effect exerted by mechanical influences has been particularly 
studied by Duncan, Meyer, Veit, and Schroeder, while Kehrer has in¬ 
sisted upon the part played by muscular action. According to Schroeder, 
three mechanical forces take part in bringing about the final shape of 
the pelvis—namely, the body weight, the upward and inward pressure 
exerted by the heads of the femora, and the cohesive force exerted at the 
symphysis pubis. 

So long as the child remains constantly in the recumbent position 
these forces are in abeyance, but as soon as it sits up or walks the body 
weight is transmitted through the vertebral column to the sacrum, and, 
as the center of gravity is anterior to its promontory, the force trans¬ 
mitted is resolved into two components, one of which is directed down¬ 
wards and the other forward. Accordingly, the two together tend to 
force the promontory of the sacrum downward and forward toward the 
symphysis pubis, a process which can only be accomplished by the sacrum 
rotating about its transverse axis, so that its tip tends to become dis¬ 
placed both upward and backward. This displacement, however, is 
resisted by the strong sacrosciatic ligaments, which therefore permit 
of only slight extension, with The result that the partly cartilaginous 
sacrum becomes bent upon itself just in front of its axis— i. e., about 
the middle of its third vertebra—so that its anterior surface becomes 
markedly concave from above downward, instead of flat as it was 
previously. At the same time the body weight forces the bodies of tb 
sacral vertebrae forward, so that they project slightly beyond the al 
thereby diminishing the transverse concavity of the sacrum. 

As the anterior surface of the sacrum is wider than its poste 
the bone tends to sink down into the pelvic cavity under the influer 
the body weight, and would prolapse completely into it were it n 
in place by the strong posterior iliosacral ligaments, which sus 
so to speak, from the posterior-superior spines of the ilium. Accc 
as the sacrum is pushed downward into the pelvic cavitv 
traction upon these ligaments, which in turn drag the posterio 
spines inward toward the middle line, and consequently tent 
the anterior portions of the innominate bones outward. Ex 
ward rotation is prevented, however, by the cohesive fore 
the symphysis, but particularly by the upward and inward 
erted by the heads of the femora. Practically, then, V 



21 


TRANSFORMATION OF FCETAL INTO ADULT PELVIS 

becomes converted into a two-armed lever, with the articular surface of 
the sacrum as a fulcrum; as a consequence, it bends at its point of least 
resistance, which is just anterior to the articulation, and thus gives the 
pelvis a greater transverse and a lesser anteroposterior diameter (Figs. 
27, 28). At the same time it must be remembered that a considerable 
part of the transverse widening is more apparent than real, and is due 
to the relative shortening of the conjugata vera by the downward and 
forward displacement of the promontory of the sacrum. 

It is apparent that the forces just mentioned must act in identically 
the same manner in the two sexes, so that, while they may serve to 
explain many points in the transformation of the fcctai into the adult 
pelvis, they fail to give a satisfactory explanation of its sexual differences, 



Fig. 27. 


Fig. 28 


Figs. 27, 28. —Diagrammatic Representations of Sections through the Infantile 

and adult Pelvis (Schroeder). 

and we are therefore compelled to agree with Falk, Fehling, Freund, 
Joessel, and Breus and Kolisko that the latter must owe their origin to 
certain congenital tendencies concerning whose nature we are as yet 
ignorant. 

Breus and Kolisko insist that too great stress has been laid upon the 
action of mechanical forces in the production of the ultimate shape of 
the pelvis, and hold that the relative flattening of the superior strait 
is due not so much to the downward and forward displacement of the 
base of the sacrum as to the unequal rate of growth before puberty of 
the sacrum and the several component parts of the innominate bones. 
r n making this contention, they lay great stress upon the so-called 
^minal length of the latter, which includes not only the linea termi- 
lis, but also its imaginary continuation, which extends from the 
•tral margin of the sacro-iliac articulation to the iliac crest just above 
urperior-posterior spine (Figs. 29, 30). In the normal adult pelvis, 
rminal length measures from 19.5 to 21 centimeters, and is divided 
ree parts—the sacral, iliac, and pubic portions. The first extends 
3 posterior margin of the iliac crest to the ventral margin of the 
surface, the second from the latter to the line upon the linea 
which indicates the union of the iliac and pubic bones, and the 






22 


THE PELVIS 


third from that point to the anterior end of the pubic bone. These 
portions measure 6.5 to 7, 6 to 6.5, and 7 to 7.5 centimeters respectively, 
and therefore are of practically equal length. During the period of 
developments, the sacral portion grows from the cartilage covering the 
iliac crest, the iliac portion from the upper limb of the ^ -shaped car¬ 
tilage of the acetabulum, and the pubic portion from the latter as well 
as from the symphyseal cartilage. 

Up to the seventh or eighth year the sacrum increases steadily in 
width, and then ceases to grow until just before puberty, when it rapidly 
attains its full development. During the former period the superior 
strait grows relatively more rapidly in its transverse diameter, and there¬ 
fore assumes a flattened shape. Normally, the iliac portion of the in- 



Fig. 29. —Showing Terminal Length Fig. 30. —Showing Terminal Length 

as SEEN FROM ABOVE. X AS SEEN FROM BELOW. X Bi- 

nominate bone increases steadily in length, until it has attained its full 
development just before puberty, while the sacral and pubic portions 
grow much more slowly. Accordingly, as a result of these variations 
combined with the arrested growth of the sacrum, the anteroposterio 
diameter of the superior strait will at some time equal or exceed t 1 
transverse diameter in length, so that between the eighth and twel 
years the pelvic inlet will become round or even oval in shape, with 
long diameter extending anteroposteriorly. This, however, is 01 
transient phenomenon, as shortly before puberty the sacrum sud 
begins to increase rapidly in width, and the pubic bones in lenp 
that the superior strait reassumes its typical flattened shape w 
long diameter extending transversely. 

Breus and Kolisko, therefore, contend that these variations 
that the changes in shape of the pelvis must be attributed to i 
more than mere mechanical influences, since the latter come ir 
infancy and continue as long as the individual is able to sit l 
Were they the only factors concerned, the pelvis would necc 





TRANSFORMATION OF FGETAL INTO ADULT PELVIS 


23 


tinue to become more and more flattened, until it had attained its ulti¬ 
mate form, whereas the occurrence of a rounded superior strait between 
the eighth and twelfth year clearly indicates that some other factor must 
be concerned. As yet they have advanced no explanation for the variable 
rate of growth of the sacrum and the component parts of the innominate 
bone, but they nevertheless hold that its occurrence precludes the ac¬ 
ceptance of the mechanical theory to the exclusion of all others, while 
at the same time they admit that the latter may also play an important 
part in the development of the pelvis. 

The effect of the mechanical factors is particularly emphasized in 
the production of certain varieties of contracted pelvis, which have been 
studied by Yon Meyer and Schroeder. In rare instances, as in one 
recorded by Gurlt, none of the mechanical forces come into play, and 
then one has an opportunity of studying the development of the pelvis 
in their absence. In Gurlt’s case, autopsy upon a thirty-one-year-old 
hydrocephalic woman, who had been bedridden since infancy and had 
never sat or walked, showed that the pelvis had retained its foetal char¬ 
acteristics. 

The cohesive force exerted at the symphysis pubis cannot act by itself, 
as it is manifested only when the force exerted by the body weight causes 
a tendency toward gaping of the pubic bones. Likewise, the effect of the 
upward and inward force exerted by the femora cannot be observed by 
itself, as this force comes into play only when it has to react against that 
resulting from the body weight. Nor has the action of the body weight 
alone ever been observed, though theoretically it might be noted in an 
individual presenting a split pelvis (congenital lack of union at the sym¬ 
physis pubis) who had never walked. Its action, however, has been 
studied experimentally by Freund, who suspended a cadaver by the iliac 
crests after cutting through the symphysis, and found that the innomi¬ 
nate bones gaped widely. 

The effect of the combined action of the body weight and the force 
exerted by the femora has been studied by Litzmann in cases of congeni¬ 
tal absence of the symphysis pubis. In such circumstances there is a 
marked transverse widening of the posterior portion of the pelvis, while 
the force exerted by the femora causes the anterior portions of the in¬ 
nominate bones to become almost parallel. 

The action of the body weight and the cohesive force exerted at the 
symphysis, without the upward and inward pressure exerted by the 
femora, can be studied in individuals whose lower extremities are absent, 
nd occasionally in cases of congenital dislocation of the hips. Holst 
rs described a case in which the lower extremities were congenitally 
lent, the pelvis being characterized by a marked increase in width and 
arked decrease in its anteroposterior diameter. Owing to the ex- 
re pressure exerted upon the tubera ischii in the absence of the 
macting force exerted by the femora, the innominate bones are 
\ in such a manner as to turn their crests inward and the tubera 
tward, thus producing a marked transverse widening of the in- 
ait. More or less similar changes may be observed in cases of 
dislocation of the hip if the patients have never walked. 


24 


THE PELVIS 


The effect of the various mechanical influences is particularly empha¬ 
sized when they are exerted upon pelves whose bones are softened by dis¬ 
ease, as in rachitis and osteomalacia. Consideration of the changes 
so produced will be deferred until the study oi the deformed pelves is 
taken up. 


LITERATURE 

Acosta-Sison. Pelvimetry and Cephalometry among Filipinos, Philippine J. Sci., 
1914, x, 493-97. 

Adair. The ossification centers of the fetal pelvis. Am. J. Obst., 1918, lxxviii, 
175-199. 

Arantius. Anatomicse observationes. Venetiis, 1857, Cap. xxxix. 

Balandin. Klinische Vortrage, St. Petersburg, 1883, Heft 1. 

Breisky. Zeitschrift der Gesellsch. der Ae.rzte. Wien. 1865, i, 21. 

Breus and Kolisko. Die pathologische Beckenformen. Leipzig u. Wien, Bd. I, 
Theil 1, 1900; Theil 2, 1904. 

Columbus. De re anatomica Libri XV, Venetiis, 1559. 

De Fremery. De mutationibus figures pelvis. D. I., Lugd. Batav., 1793. 

Denman. An Introduction to the Practice of Midwifery. London, 1787-1795. 

Deventer. Neues Hebammenlicht, etc. III. Aufl., Jena, 1728. 

Duncan. Researches in Obstetrics. Edinburgh, 1868. 

(On the Os Sacrum, 55-82.) 

(On the Development of the Female Pelvis, 95-113.) 

Falk. Die Entwickelung und Form des Beckens. Berlin, 1908. 

Fehling. Die Form des Beckens beim Fotus und Neugeborenen. Archiv f. Gyn., 
1876, x, 1-80. 

Freund. Ueber das sogenannte kypliotische Becken, etc. Gynakologische Klinik, 
1885, i, 1-113. 

Gache. Le Racliitisme en Amerique, etc. Annales de gyn. et d’obst., 1903, lx, 
175-195. 

Gurlt. Ueber einige Missgestaltungen des weiblichen Beckens. Berlin, 1854. 

Hegar. Zur Geburtsmechanik. (Die Beckenaxe.) Archiv f. Gyn., 1870, i, 193- 
223. 

Hodge. The Principles and Practice of Obstetrics. Philadelphia, 1860. 

Holst. Beschreibung des Beckens u. der Geburtstheile eines 40 Jahre alten 
weiblichen Amelus. Holst’s Beitrage, 1869, Heft 2, 145-148. 

Huwfi. Onderwys der vrouwen, etc. Haarlem, 1735. 

Joessel and V aldeyer. Lehrbuch der topographisch-chirurgischen Anaton 
Bonn, 1899. II Theil, Das Becken. 

Jurgens. Beitrage zur normalen und path. Anatomie des menschlichen Be' 
Virchow’s Festschrift, Berlin, 1891. 

Kehrer. Beitrage zur vergl. u. exper. Geburtshiilfe, 1869, Heft 3; und 
Heft 5. 

Kuttner. Experimentell-anat, Untersuchungen fiber die Veranderlicb 
Beckenraumes Gebarender. Hegar’s Beitrage, 1898, i, 210-229. 

Levret. L’art des accouchements. Paris, 1751. 

Litzmann. Die Formen des Beckens. Berlin, 1861. 

Das gespaltene Becken. Archiv f. Gyn., 1872, iv, 266-284. 

Die Geburt bei engem Becken. Leipzig, 1884. 

Loeschke. Untersuchungen fiber Entstehung und Bedeutung der £ 
in der Symphyse. Archiv f. Gyn., 1912, xcvi, 525-560. 

Lusciika. Die Anatomie des menschlichen Beckens. Tfibingen, l r 











LITERATURE 


55 


LITERATURE 

Ancel et Bouin. Sur 1’existence d’une glande myometriale endocrine, etc. 

Comptes rendns de 1’assoc, des anatomistes, Paris, 1911. 

Bayer. Zur physiol, und path. Morphologic der Gebarmutter. Freund’s Gynfiko- 
logische Klinik, 1885, 369-662. 

Bruhns. Ueber die Lymphgefasse der weiblichen Genitalien. Archiv f. Anat. u. 

Physiol., Anat. Abtheil., 1898, 57. 

Championniere. Les lymphatiques uterines. Paris, 1875. 

Clark. The Causes and Significance of Uterine Haemorrhage in Cases of Myoma 
Uteri. Johns Hopkins Hospital Bulletin, 1899, 11-20. 

Dahl. Die Innervation der weiblichen Genitalien. Zeitschr. f. Geb. u. Gyn., 1916, 
lxxviii, 539-601. 

Duvelius. Zur Kenntniss der Uterusschleimhaut. Zeitschr. f. Geb. u. Gyn., 1884, 
x, 175-187. 

Engelman. The Mucous Membrane of the Uterus. Amer. Jour. Obst., 1875, viii, 
30-86. 

Farabeuf. Les vaisseaux sauguins des organes genito-urinaires. Paris, 1905. 
Fischel. Beitrage zur Morphologic der Portio vaginalis uteri. Archiv f. Gyn., 
1880, xvi, 192-202. 

Fraenkel. Untersuchungen fiber die sogenannte il glande endocrine myometriale.” 

Archiv f. Gyn., 1913, xeix, 225-230. 

Frankenhauser. Die Nerven der Gebarmutter. Jena, 1867. 

Freidlander, C. Phys. anat. Untersuchungen fiber den Uterus. Leipzig, 1870. 
Freidlander, F. Abnorme Epithelbildung im kindlichen Uterus. Zeitschr. f. 
Geb. u. Gvn., 1898, xxxviii, 8-16. 

IJerlizka. Quoted by Joessel-Waldeyer, Das Beckon. Bonn, 1899, 764. 

His. Die anatomische Nomenclatur. Leipzig, 1895. 

Hitschmann und Adler. Der Ban der Uterusschleimhaut des gcschlechtsreifen 
Weibes, etc. Monatsschr. f. Geb. u. Gyn., 1908, xxviii, 1-81. 

Hoehne. Flimmerung im Gebiete des weibl. Genitalapparates. Zentralb. f. Gyn., 
1908, 121-125. 

Hofmeier. Zur Kenntniss der normalen Uterusschleimhaut. Zent.ralbl. f. Gyn., 
1893, 764-766. 

Johnstone. The Function and Pathology of the Reticular Tissue. Amer. Gyn. 
and Obst. Jour.,1896, ix, 166-187. 

Jung. Die Anatomie und Physiologic des Beckenbindegewebes. Martin’s Krank- 
lieiten des Beckenbindegewebes, 1906, 1-49. 

Kocks. Die normale und path. Lage des Uterus, etc. Bonn, 1880. 

Kownatski. Die Venen d. weibl. Beckens. Wiesbaden, 1907. 

Kreitzer. Anatomische Untersuchungen fiber die Muskulatur der nicht schwan- 
geren Gebarmutter. Petersburg, med. Zeitschrift, 1871, 113. 

Latarjet et Rochet. Le plexus hvpogastrique chez la femme. Gyn. et Obst., 
1922, vi, 225-243. 

Lee. On the Ganglia and Other Nervous Structures of the Uterus. London, 1842. 
Leopold. Die Lymphgefasse des normalen, nicht schwangeren, Uterus. Archiv i. 
Gyn., 1874, vi, 1-55. 

Studien fiber die Uterusschleimhaut. Berlin, 1878. 

Luschka. Die Anatomie des Beckens. Karlsruhe, 1873. 

Mackenrodt. Ueber die Ursachen der normalen und path. Lagen des Uterus. 
Archiv f. Gyn., 1895, xlviii, 393-421. 

Mandl. Ueber die Richtung der Flimmerbewegung im menschlichen Uterus. 
Zentralbl. f. Gyn., 1898, 322-328. 



56 THE FEMALE ORGANS OF GENERATION 

Ueber das Epithel im geschleehtsreifen Uterus. Zentralbl. f. Gyn., 1908, 425- 
429. 

Martin. Der Haftapparat der weibl. Genitalien. Berlin, 1911. 

Meyer. Ueber die fotale Uterusschleimhaut. Zeitschr. f. Geb. u. Gyn., 1898, 
xxxviii, 234-249. 

Minot. Human Embryology, 1892, 3. 

Nagel. Die weiblichen Geschlecditsorgane (Bardeleben ’s Handbuch der Anatomie), 
Jena, 189G, 87-90. 

Parviainen. Zur Kenntniss der senilen Veranderungen der Gebarmutter. Berlin, 
1897. 

Pick. Ueber das elastische Gewebe in der normalen und path, veranderten 
Gebarmutter. Volkmann’s Sammlung klin. Vortrage, N. F., 1900, Nr. 283. 

Poirier. Lymphatiques des organes genitaux de la femme. Paris, 1890. 

Eibemont-Dessaignes. Precis d’obstetrique. Paris, 1894, 30. 

Rielander. Das Paroophoron. Marburg, 1905. 

Roesger. Zur fotalen Entwickelung des menschlichen Uterus. Festschrift zum 
50-jahrigen Jubilaum der Gesell. f. Geb. u. Gyn. in Berlin, 1894, 9-52. 

Rosenmuller. Quaedam de ovariis embryorum et fcetuum humanorum. Lipsiae, 
1802. 

Ruge. Zur Erosionsfrage. Zeitschr. f. Geb. u. Gyn., 1882, vii, 231-233. 

Sampson. The Escape of Foreign Material from the Uterine Cavity into the 
Uterine Veins. Am. Jour. Obst., 1918, lxxviii. 

Schauta. ‘Lehrbuch der gesammten Gynakologie. Wien, 1896, 5-14. 

Schroeder. Anat. Studien zur normalen und path. Phvsiologie des Menstrua- 
tionszyklus. Archiv f. Gyn., 1915, civ, 27-102. 

Tarnier. Traite de l’art des accouchements. Paris, 1888, T. I., 106. 

Veit. Uterusmuskulatur. Muller’s Handbuch der Geburtshiilfe, 1888, i, 122-129. 

Werth. Untersuchungen iiber die Regeneration der Schleimhaut nach Ausschabung 
der Uteruskorperhohle. Archiv f. Gyn., 1895, xlix, 369, 370. 

Zur Lehre von den Blutgefassen der normalen und kranken Gebarmutter. Jena, 
1904. 

Werth und Grusdew. Untersuchungen liber die Entwickelung und Morphologic 
der menschlichen Uterusmuskulatur. Archiv f. Gyn., 1898, lv, 325-413. 

Zeller. 1 lattenepithel im Uterus. Zeitschr. f. Geb. u. Gyn., 1885, xi, 56-88. 


THE FALLOPIAN TUBES 

The fallopian or uterine tubes are more or less convoluted muscular 
canals which extend from the uterine cornua to the ovaries. They are 
covered by peritoneum and possess a lumen lined by mucous membrane. 
They represent the excretory ducts of the ovaries, as it is through 
them that the ova gain access to the uterine' cavity. They are more or 
less cylindrical in shape, and vary from 8 to 14 centimeters in length. 

For convenience in description, each tube may be divided into several 
parts—the uterine portion, isthmus, ampulla, and infundibulum. The 
uterine portion is included within the muscular wall of the uterus, and 
extends from the cornu to the upper angle of the uterine cavity. Its 
lumen is so small that it will admit only the finest probe. The isthmus 
is the narrow portion of the tube immediately adjoining the uterus, and 
gradually passes into the wider lateral portion or ampulla. The in¬ 
fundibulum, or fimbriated extremity, is the funnel-shaped opening of 






THE FALLOPIAN TUBES 


57 


the lateral end of the tube, the margins of which present a dentate ap¬ 
pearance (see Figs. 43 to 45, and Fig. 65). 

The tube varies considerably in thickness, the narrowest portion of 
the isthmus measuring from 2 to 3 millimeters, and the widest portion 
of the ampulla from 5 to 8 mil limete rs in diameter. 

With the exception of its uterine portion, the tube, throughout its 
entire length, is included within the upper margin of the broad ligament; 
it is completely surrounded by peritoneum .except at its lower portion, 
corresponding to the mesosalpinx. The fimbriated^extremity opens 
freely into the abdominal cavity, and one of its fimbriae—the fimbria 



Fig. 61.— Tubal Mucosa. X 280. 


ovaried —which is considerably longer than the others, forms a shallow 
gutter which extends almost or quite to the ovary. 

Generally speaking, the musculature of the tube is arranged in two 
layers—an inn er, circular , and an outer, longitudinal layer. In its 
uterine portion a third layer, lying between the circular layer and the 
mucosa, and composed of longitudinal fibers, may be distinguished. 
In the lateral portion of the tube the two primary layers become less 
marked, and in the neighborhood of the fimbriated extremity are 
replaced by an i nterlacing network of muscle fibers. The writer was 
the first to call attention to the presence of the inner longitudinal layer 
in the uterine portion of the tube, and his observations have been 
generally confirmed. 

The lumen of the tube is lined with a mucous membrane whose 
epithelium is composed of a single layer of high, columnar cells, which 
rest upon a thin basement membrane (Fig. 61). According to Schaffer, 
only a portion of the cells are ciliated. These are arranged in discrete 











58 


THE FEMALE ORGANS OF GENERATION 



patches, while the non-ciliated cells are supposed to be secretory. 
Grosser, on the other hand, contends that the great majority are ciliated. 
There is no submucosa, the epithelium being separated from the under¬ 
lying muscle by a layer of connective tissue of varying thickness. 


Fig. 63 


Figs. 



62 64. Sections through Uterine, Isthmic, and Ampullar Portions of Tube 

X 15. 






THE FALLOPIAN TUBES 


59 


The mucosa is arranged in longitudinal folds which become more 
complicated as the fimbriated end is approached. Consequently, the 
appearance of the lumen varies according to the portion of the tube 
examined. In cross sections through the uterine portion four simple 
folds are seen, which together make a figure resembling a Maltese cross. 
In the isthmic portion a more complicated appearance can be noted; 
while in the ampulla the lumen is almost completely occupied by the 
arborescent mucosa, which upon careful examination is seen to be made 
up of four very complicated treelike folds (Fig. 65). 

The statements of Hennig and Bland-Sutton that the tube possesses 
glands have since been found to be erroneous, inasmuch as the structures, 
which they considered as such, are merely depressions between folds of 
the mucosa. This was conclusively demonstrated by Frommel, who 
showed that the glandular appearance disappeared upon distending the 



Fig. 65. —Longitudinal Folds of Tubal Mucosa (after Sappey). 


tube, when the greater part of its lumen became perfectly smooth, with 
four arborescent folds of mucosa arising from its sides. It is interesting 
to note that Nature sometimes performs a similar experiment in cases 
of hydrosalpinx. 

The current produced by the cilia of the tube is directed from the 
fimbriated extremity toward the uterus, as was first demonstrated by the 
experiments of Pinner, Jani, and Lode, who showed that minute foreign 
bodies introduced into the abdominal cavity of animals eventually ap¬ 
peared in the vagina, after making their way down the lumen of the 
tubes and the cavity of the uterus. Contrary to the teaching of many 
that peristaltic muscular contraction is the main factor concerned in the 
downward passage of the ovum, Grosser contends that the ciliary current 
plays the principal part. 

The tubes are richly supplied with elastic tissue, blood vessels and 
lymphatics, and the latter sometimes become so dilated as to fill up 
almost entirely certain folds of the mucosa. 

Occasionally, as Pichard first pointed out, the tube may possess a 
second fimbriated extremity, which is known as an accessory ostium (Fig. 
66). Again, small tubelike structures, with miniature fimbriated ex¬ 
tremities, frequently project from the exterior of the tube. As a rule. 



60 THE FEMALE ORGANS OF GENERATION 

these are mere culdesac, but occasionally one is met with possessing a 
lumen which communicates with that of the main tube. In se\eial 
instances of extra-uterine pregnancy has followed the arrest of the fer¬ 
tilized ovum in such a structure. 

Similar formations are frequently observed upon the anterior surface 
of the mesosalpinx, but have no connection with the tube. 1 hey have 
been studied more particularly by Kossmann, who designated them as 
accessory tubes. They are probably derived from aberrant portions of 
the coelomic epithelium. 

In very exceptional instances there may be two tubes on one side, 
Bab having reported two cases of his own, together with five others 
collected from the literature. 

Diverticula may occasionally extend from the lumen of the tube for 
a variable distance into its muscular wall, and reach almost to its 



Fig. 66.—Tube with Accessory Ostium. 


peritoneal covering. Such structures were first described by Landau 
and Rheinstein and myself. The suggestion that they might play a part 
in the production of tubal pregnancy would seem plausible, inasmuch 
as a fertilized ovum, which might chance to make its way into such a 
diverticulum, would be arrested at its tip and there develop, if suitable 
conditions existed. 

In rare instances the main canal of the tube may branch, and two 
or even three lumina may be seen in sections. After extending for a cer¬ 
tain distance, more or less parallel to the main lumen, they usually 
rejoin it. It should always be borne in mind that such appearances 
are usually due to the fact that two or more twists or bends of the tube 
have been included in one section; although in several instances, by 
the use of the serial method, I have been able to demonstrate that more 
than one lumen really existed. 

In the new-born child the tubes are. markedly convoluted, and pre¬ 
sent a cork-screwlike appearance, as shown in Fig. 43. This gradually 
disappears with age, but occasionally the foetal condition persists and 
may play a not unimportant part in the production of sterility and tubal 
disease, as was first pointed out by Freund and Schober. 


THE OVARIES 


61 


LITERATURE 

Bab. Ueber duplicitas tubae Fallopii. Archiv f. Gyn., 1906, Ixxviii, 391-401. 
Ballantyne and Williams. The Histology and Pathology of the Fallopian 
Tubes. British Medical Journal, January 17 and 24, 1891. 

Freund. Ueber die Indicationen zur operativen Beliandlung der erkrankten Tuben. 

Volkmann’s Sammlung klin. Vortrage, 1888, Nr. 323. 

Frommel. Beitrage zur Histologic dcr Eileiter. Verh. der deutsclien Gesell. f. 
Gyn., 1886, 95. 

Grosser. Ovulation und Implantation und die Funktion der Tube beim Menschen. 
Archiv f. Gyn., 1919, cx, 297-327. 

Hennig. Ueber die Blindgange der Eileiter. Archiv f. Gyn., 1878, xiii, 156. 
Jani. Ueber das Vorkommen von Tuberkelbacillen im gesunden Genitalapparat 
bei Lungenschwindsucht, etc. Virchow’s Archiv, ciii, 522. 

Kossmann. Ueber accessorisclie Tuben und Tubenostien. Zeitschr. f. Geb. u. 
Gyn., 1S94, xxix, 253-268. 

Landau und Rheinstein. Beitrage zur path. Anatomie der Tuben. Archiv f. 
Gyn., 1891, xxxix, 273-290. 

Lode. Exp. Beitrage zur Lehre von der Wanderung des Eies vom Ovarium zur 
Tube. Archiv f. Gyn., 1894, xlv, 295-324. 

Mandl. Ueber den feineren Bau der Eileiter, etc. Monatsschr. f. Geb. u. Gyn., 
1897, v. Erganzungs Heft, 130-140. 

Pick. Ein neuer Typus des voluminosen parooplioralen Adenomyoms. Archiv f. 
Gyn., 1897, liv, 117-206. 

Pinner. Ueber den Eintritt des Eies aus dem Ovarium in die Tube, etc. Archiv 
f. Anat. u. Phys., Physiol. Abth., 1880, 241. 

Richard. Pavilions multiplies. Gaz. Med. de Paris, No. 26, 1851. 

Schaffer. Ueber Bau u. Funktion d. Eileiterepithels. Monatsehr. f. Geb. u. 
Gyn., 1908, xxviii, 526-542. 

Schober. Ueber Erkrankungen gewundener Tuben. D. I., Strassburg, 1889. 
Sutton. Glands of the Fallopian Tube and Their Function. Trans. London Obst. 
Soc., 1888, xxx, 207-213. 

Williams. Contributions to the Normal and Pathological Histology of the Fal¬ 
lopian Tubes. Amer. Jour. Med. Sciences, October, 1891. 


THE OVARIES 

General Anatomy.—The ovaries are two flattened, more or less 
almond-shaped organs, whose chief functions are the development and 
extrusion of ova, and the elaboration of an internal secretion. I h<*\ 
may vary considerably in size, and during the child-bearing period 
measure from 2.5 to 5 centimeters in length, 1.5 to 3 centimeteis in 
breadth, and 0.6 to 1.5 centimeters in thickness (see Fig. 45). After 
the menopause they diminish markedly in size, and in old women are 

often scarcely larger than peas. 

Normally, the ovaries are situated in the upper part of the pelvic 
cavity, one surface of each ovary resting in a slight depression m the 
upper portion of the inner surface of the obturator muscle—the fossa 
ovarica of Waldeyer. With the woman standing, the long axes of the 
ovaries occupy an almost vertical position, which becomes horizontal 





62 THE FEMALE ORGANS OF GENERATION 

when she is on her back. Their situation, however, is subject to marked 
variations, and it is rare to find both ovaries at exactly the same level. 

Each ovary presents for examination two surfaces, two margins, and 
two poles. The surface which is in contact with the ovarian fossa is 
called the lateral, and the one directed toward the uterus is known as the 
median surface. The margin which is attached to the mesovarium is 
more or less straight, and is designated as the hilum, while the free 
margin is convex and is directed backward and inward toward the 

rectum. The extremities of the ovary 
are termed the upper and lower, or 
tubal and uterine poles respectively. 

The ovary is attached to the broad 
ligament by the mesovarium, which 
forms the posterior leaf of that struc¬ 
ture. The ovarian ligament extends 
from the lateral and posterior portion 
of the uterus, just beneath the tubal 
insertion, to the uterine or lower pole 
of the ovary. It is usually several cen¬ 
timeters long and 3 to 4 millimeters in 
diameter. It is covered by peritoneum, 
and is made up of muscle and connec¬ 
tive-tissue fibers, which are continuous 
with those of the uterus. The in- 
fundibulopelvic or suspensory ligament 
of the ovary extends from its upper or 
tubal pole to the pelvic wall. It rep¬ 
resents the portion of the upper margin 
of the broad ligament which is not 
occupied by the tube, and through it 
the ovarian vessels gain access to the 
broad ligament. 

For the most part the ovary pro¬ 
jects freely into the abdominal cavity, 
and is not covered by peritoneum ex¬ 
cept near its hilum, where a narrow 
is continuous with the peritoneum 
covering the mesosalpinx. It follow's, therefore, that over its lower 
portion only can be noted the glistening appearance characteristic of 
peritoneum, while the greater part of its surface is of a dull white color 
and looks moist. This distinction was discovered by Farre, but its 
importance was first emphasized by Waldeyer (Fig. 72), who showed 
that the ovary above the peritoneal line was covered by cuboidal epi¬ 
thelium. 

In many of the lower animals, as in the rat, the ovary does not 
project freely into the abdominal cavity, but is inclosed in a peritoneal 
sac, into which opens the fimbriated end of the tube. In the cow, dog, 
and cat there is more or less free communication between the former and 
the peritoneal cavity. 



Fig. 67. — Cross - section Adult 
Ovary. X 4. 

band may be observed which 




THE OVARIES 63 

The exterior of the ovary varies in appearance according to the age 
of the individual. In young women the organ presents a smooth, dull 
white surface, through which glisten a number of small, clear vesicles— 
the graafian follicles. As the woman grows older it takes on a more 
corrugated appearance, which in the aged may become so marked as to 
be suggestive of the convolutions of the brain. 

The general structure of the ovary can best be studied in cross- 
sections, when the organ is seen to be made up of two portions: the 
cortex and medulla, or zona parenchymatosa and zona vasculosa. The 
cortex or outer layer varies in thickness according to the age of the 
individual, becoming thinner with advancing years. In this layer the 
ova and graafian follicles are situated. It is composed of spindle-shaped 
connective-tissue cells, through which are scattered primordial and 
graafian follicles in various stages of development, which become less 
numerous as the woman grows older. The most external portion of 
the cortex presents a dull whitish appearance, and is designated as the 
albuginea, though it is not analogous with the similarly named structure 
in the testicle; on its surface is a single layer of cuboidal epithelium—- 
the ovarian epithelium of Waldeyer. 

The medulla or central portion of the ovary is composed of loose con¬ 
nective tissue, which is continuous with that of the mesovarium. It 
contains large numbers of blood vessels, both arteries and veins; and, 
according to His, Kollicker, and Rouget, a considerable number of non- 
striated muscle-fibers, whose presence caused the last-named observer 
to class it among the erectile tissues. The arrangement of the blood 
vessels has been studied exhaustively by Clark, to whose admirable mono¬ 
graph we would refer those interested in the subject. 

In the neighborhood of the hilum one occasionally observes short 
ducts or tubes, which are lined by a single layer of columnar epithelium. 
Their significance is not clear, and it is difficult to determine whether 
they represent remnants of the rete ovarii or of the wolffian bodies. 

In the human foetus collections of epithelial cells are frequently 
observed in the neighborhood of the hilum, which are arranged in masses 
or strands sharply marked off from the surrounding stroma. These 
are the medullary cords of Kollicker, who believed that they represented 
portions of the wolffian body which had become included within the 
ovary. The investigations of Coert, Winiwarter, and other authorities 
have shown, however, that these cells represent the remains of the first 
proliferation of the germinal epithelium, and are analogous to the semi¬ 
niferous tubules of the testicle. In early embryos the lower extremities 
of the medullary cords develop lumina which eventually communicate 
with the tubules of the epoophoron (rete ovarii) (Fig. 71). In the 
female this is only a transient phenomenon, and usually disappears 
before birth; but in the male it persists and affoids a satisfactory ex¬ 
planation for the employment of the wolffian ducts as the efferent 
channels for the testicles. On the other hand, the medullary cords are 
persistent and characteristic structures in many of the lower animals. 

Moreover, in many of the lower animals the medulla of the ovary 
is occupied to a variable extent by masses of characteristic epithelioid 




64 


THE FEMALE ORGANS OF GENERATION 


cells, somewhat resembling those making up the corpus luteum. Limon 
in 1901 called attention to their existence, and his findings were con¬ 
firmed by Bouin, Aime, and others. The origin of the cells is not clear, 
but, as they are supposed to take part in the formation of the internal 
secretion, they are sometimes designated as the interstitial gland of the 
ovary. Strictly speaking, no such gland exists in women, and great 
confusion would have been avoided had many writers, who had no con¬ 
ception of the histological structure of the ovary, not allowed their 
imagination to run riot; as has happened in the case of Lipschiitz, in 
whose monograph it is described as the "puberty gland,” and every occur¬ 
rence in the sexual life of women, except fertilization, is attributed to it. 

The researches of L. Fraenkel, Schaeffer and Meyer confirm this 
view. On the other hand, Wallart, Aschner and Seitz have applied 
the term to the hypertrophic theca cells which develop about the 
periphery of follicles which are undergoing atresia, and Aschner has 
shown that such "interstitial glands” are not present in the nonpregnant 
adult woman, but are well marked before puberty and during pregnancy. 
They believe that these transient structures give rise to an internal 
ovarian secretion, and when present play an important part in the 
economy of the individual. 

The nerves of the ovary are derived in great part from the sympa¬ 
thetic plexus which accompanies the ovarian vessels—the so-called 
ovarian plexus, while a few are derived from the plexus surrounding 
the ovarian branch of the uterine artery. Their finer anatomy, after 
they enter the ovary, has been studied by numerous investigators, among 
whom may be mentioned Yon Herff, Abel and Mcllroy, and Wallart. 
The consensus of these researches is that the ovary is very richly supplied 
with non-medullated nerve-fibers, which for the most part accompany 
the blood vessels, and are merely vascular nerves; whereas others form 
wreaths around normal and atretic follicles and give off many minute 
branches, which have been traced up to, but not through, the mem- 
brana granulosa. 

Elizabeth Winterhalter has described a collection of ganglionic cells 
in the medulla of the ovary which she designates as the ovarian ganglion; 
while Dahl is equally positive in denying their presence. 

Accessory Ovaries.—Waldeyer, in 1870, directed attention to the oc¬ 
casional presence of accessory bodies which are sometimes found on the 
broad ligament in the neighborhood of the main ovary. These structures 
are usually small, although in rare instances they may attain a consider¬ 
able size. Occasionally they result from faulty development, but more 
frequently are to be attributed to inflammatory changes occurring during 
fcetal life, as a consequence of which small portions of the ovary have 
been cut off from the body of the organ. The subject has been con¬ 
sidered in detail by Engstrom, Thumin, Seitz, and Chiari, and cases 
have been described in which there was found a typical third ovary con¬ 
nected with the uterus by a separate tube. 

Transplantation of Ovaries.—Experimental studies undertaken by 
Grigorieff, Knauer, Marshall, and others have shown that the ovaries 
of animals and women may be excised from their original position and 


THE OVARIES 


65 


transplanted to other portions of the body, or even into other animals 
of the same species, and that in their new situation they can establish 
ascular connections and continue their functional activity. Pregnancy 
has repeatedly followed such operations in animals. For full literature 
upon the subject up to 1922 the reader is referred to the article of 
F. H. Martin, in which it is stated that the results in women have been 
disappointing, and that while satisfactory results sometimes follow auto- 


G.E. 


P.O.. 


--AW 




i I' 

li/'/r i ’ - 


transplantation, there is little evidence in favor of homotransplantation 
and none in support of hetero-transplantation. 

Internal Secretion.— From the time that Brown-Sequard published 
his studies upon the internal secretion of the testicles, it has been more 
or less generally believed 
that the ovaries likewise 
elaborate a somewhat 
analogous product, which 
plays an important part 
in the female economy. 

Indeed, the work of 
Knauer, Mandl, Burger, 
and others indicate that 
this secretion is directly 
concerned in maintaining 
the integrity of the other 
generative organs; inas¬ 
much as they have shown 
that atrophy of the uterus 
and vagina rapidly fol¬ 
lows the removal of the 
ovaries, whereas this does 
not occur when they 
are removed from their 
normal position and 
transplanted to other 
portions of the body. 

They therefore conclude 
that in such cases the absence of atrophy must be attributed to the 
action of the internal secretion of the transplanted ovaries, since all 
nerve connections were severed at the time of operation. 

Frankel in 1903, and again in 1910, as the result of ingenious experi¬ 
ments and clinical work, stated that the internal secretion is elaborated 
in the corpus luteum. Notwithstanding considerable initial opposition, 
his views have obtained wide acceptance, and it is now generally believed 
that the structure has important secretory functions. ( linical observa¬ 
tion also lends support to such a view, as in various conditions, which 
are supposed to be associated with deficient ovarian secretion, more 
striking therapeutic results follow the administration oi tablets com¬ 
posed entirely of corpus luteum substance thau when the desiccated 
tissue of the entire ovary is employed. Reference has already been 
made to the so-called “interstitial gland,” and if the theca, which are 



Fig. 68.—Section through Wolffian Body and 
Beginning Ovary and Mullerian Duct (Wal- 
deyer). X 160. 

A.W., abdominal wall; C.E., germinal epithelium; 
M.D., beginning miillerian duct; O., beginning 
ovary; P.O., primordial ova; W.B., wolffian body. 










66 THE female organs of generation 

so designated, elaborate an internal secretion it must be closely related 

to that product by the corpus luteum. 

Development of the Ovary.—An accurate idea of the structure ot 

the ovary can he gained only through the study of its development. 
To Waldeyer we are indebted for much of our knowledge concerning 
the subject, though imnortant preliminary work had been done by A al- 

entin and Pfliiger. , 

In 1870 Waldeyer published his monograph upon the Ovary ana 
Ovum ( Eierstoclv und Ei) and, although subsequent investigation has 
invalidated many of his conclusions, it must be regarded as the founda¬ 
tion of our knowledge of the subject. His work, which was based m 
great part upon the embryology of the chicken, showed that by the 
fourth day of development the coelomic epithelium covering the inner 
surface of the wolffian body is differentiated from the surrounding tissue, 

its cells becoming larger and more cuboidal in shape, and some of them 

assuming a considerable 

size. Within a short time the 
epithelium proliferates to 
such an extent as to form a 
distinct elevation, which in¬ 
dicates the situation of the 
future ovary (Fig. 68). 
This epithelium Waldeyer 
designated as germinal epi¬ 
thelium and the large, clear 
cells found within it as 
primordial ova. As the pro¬ 
liferation continues, a mass 
of cells is formed consisting of large primordial ova and smaller 
epithelial cells. By the upward growth of the connective tissue and 
blood vessels from the wolffian body, the epithelial masses become divided 
into smaller portions, the so-called egg-nests or PfliigePs tubes, which in 
turn become broken up into smaller and smaller masses, until eventually 
isolated primordial ova are found, which are surrounded by a single 
layer of more or less flattened epithelium. These represent the primordial 
follicles. 

Thirty-one years later, however, Waldeyer stated that the process 
was not so simple, and the work of Nagel, Wendeler, Winiwarter, 
Skrobansky, and Mcllroy clearly shows that in the higher animals, at 
least, the process of development is quite different. In either sex, the 
first trace of the sexual glands is found in a thickening of the epi¬ 
thelium on the inner surface of the wolffian body. These primitive sex 
cells rapidly proliferate and give rise to a distinct elevation, made up 
of closely packed undifferentiated epithelial cells, which are covered 
by a single layer of cuboidal cells arranged perpendicularly to the surface 
of the mass. The latter correspond to the future ovarian epithelium 
and take no part in the formation of ova and follicles (Fig. 69). 

The cells of the primitive sex gland proliferate rapidly and invade 
the underlying stroma of the wolffian body, so that a cortical and medul- 



Fig. 69.—Sex Gl\nd of Pig Embryo, 1.2 cm. 
long (Skrobansky). 






THE OVARIES 


67 



lary portion can be distinguished at an early period. The epithelial 
cells soon become broken up into irregular masses by the upgrowth of 
connective tissue and have little or no connection with the surface 
epithelium. The most deeply lying cells do not become differentiated, 
but extend downwards as solid cords—the 
medullary cords. These terminate in a 
series of epithelial tubes—the so-called rete 
ovarii, which in turn communicate with 
the wolffian body tubules. In the female 
this is a transient condition, which dis¬ 
appears early in foetal life, but in the 


STS' 


Fig. 70. —Cortex of Pig Embryo, showing Ger- Fig. 71. —Diagram showing Forma- 
mnal Epithelium, Pfluger’s Tubes with tion of Ovary (Winiwarter). 
Oocytes in Various Stages of Development germinal epithelium; 2, germ tube; 
'Skrobansky). 3, medullary cord; 4, rete ovarii; 

5, epoophoron 


male it is permanent and affords a ready explanation for the utilization 
of the wolffian ducts as the efferent channels of the testicles (Fig. 71). 
The more superficial cells become arranged in irregularly shaped masses, 
continue to proliferate, and soon show signs of differentiation. Many 
become large cells with prominent clear nuclei, whose chromatin takes 
on a different arrangement, while others retain their original appearance. 
The former are the oogonia, from which the ova are to be developed, 
while the latter give rise to the follicular epithelium. 















68 THE FEMALE ORGANS OF GENERATION 

After a certain period the oogonia cease proliferating, when the 
resulting cells become larger, and their chromatin undergoes a series of 
complicated changes, which eventually lead to the formation of the 
reticulated nucleus of the primordial ovum or oocyte of the first order 
(Fig. 70). By the continued growth of connective tissue the masses 
of oocytes and undifferentiated epithelial cells become still further 
broken up, so that eventually each oocyte is surrounded by a single layer 
of flattened cells, thus giving rise to a primordial follicle. 

That there is no essential difference between the differentiated and 
undifferentiated cells is shown by the fact that the cells of the medullary 
cord, which are of the latter variety, may develop into typical oocytes; 



Fig. 72. —Ovary of New-born Girl. X 22. 

these, however, do not give rise to primordial follicles, but degenerate vn 
situ. It would thus appear that the primordial ova or oocytes do not 
develop from the surface epithelium, but rather from the undifferentiated 
cells of the primitive sexual glands. 

This process has been observed by all recent investigators in rabbits, 
pigs, and human beings. In the latter the formation of oocytes ceases 
before birth, but in some of the lower animals, especially in the bat, 
the process may continue throughout life. 

At birth the greater part of the ovary consists of the cortex, which 
is made up of closely packed primordial follicles, which are separated 
from one another by very thin bands of connective tissue, although 
occasionally small groups of follicles may he in direct contact (Figs. 72 
and 73). At this period the surface of the ovary is covered by a single 
layer of cuboidal epithelium which shows no signs of proliferation. 

All authorities agree that the primordial ova are derived from the 
primary sex cells, but there is still considerable discussion as to the 
origin of the epithelium surrounding them. According to Waldeyer 












THE OVARIES 


69 


and most other observers, the follicular epithelium is derived from the 
cells of the germinal or sexual epithelium, which have not been con¬ 
verted into oocytes. Kollicker, on the other hand, believed that it 
originated from the epithelium of the wolffian bodies, and that the 
medullary cords in the adult ovary represented portions which had not 
been utilized in this way. Foulis, in 1878, stated that the so-called 
follicular epithelium was derived from the connective tissue of the 
ovary, and later studies by Wendeler and Clark would seen to confirm 
this view. 

Waldeyer’s teachings, however, have obtained almost universal ac- 



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Sr. 




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Fig. 73. —Cortex of Ovary at Birth showing Primordial Follicles. X 300. 


ceptance, and are placed beyond all reasonable doubt by the work of 
Winiwarter and McTlroy, so that it would seem advisable to dismiss 
Foulis's theory as untenable. 

In rare instances the surface epithelium of the ovary may be ciliated, 
and now and again, as has been pointed out by Von Velits and myself, 
the follicular epithelium may likewise be found to possess cilia. These 
observations, in spite of their rarity, speak strongly against the con¬ 
nective-tissue origin of the follicular cells. 

Microscopic Structure of Ovary.—From the first stages of its develop¬ 
ment until after the menopause the ovary is undergoing constant change. 
According to Waldeyer, each ovary at birth contains at least 100,000 
oocytes, the majority of which disappear before the age of puberty; 
so that at that time only 30,000 to 40,000 remain, and these disappear 
during the following thirty years. That this is a moderate estimate is 


70 


TIIE FEMALE ORGANS OF GENERATION 


shown by the fact that Haggstrom was able to count 400,000 follicles 
in the ovaries of a twenty-two year old woman. As only one ovum is 
ordinarily cast off each month, it is apparent that a few hundred ova 
would suffice for the purposes of reproduction. The mode by which the 
others disappear will be considered when we take up the study of the 
corpus luteum and follicular atresia. 

Before considering the evolution of the mature follicle, it may be 
well to mention certain historical points in connection with it. The 
graafian follicle was first described in 1672 by De Graaf, a physician 
of Delft, who not only observed the vesicles, but demonstrated the pres¬ 
ence of ova in the tubes of rabbits. The human ovum was first recog¬ 
nized by Yon Baer in 1827, its nucleus or germinal vesicle by Purkyne 
in 1830, and its nucleolus or germinal spot a few years later by Wagner. 

In 1891 Boveri pointed out that the nomenclature usually employed 
in connection with the specific cells of the ovary was faulty. He con¬ 
tended that the terms ovum and egg are synonymous, and should there¬ 
fore be restricted to cells which are ready for fertilization. As this is 
the case only after the completion of maturation and the casting off 
of the polar bodies, he suggested that other terms be employed prior 
to that period. Accordingly, he designated the cells during the stage of 
division as oogonia, from then until maturation begins as oocytes of the 
first order, after the formation of the first polar body as oocytes of the 
second order, and as ova only after the formation of the second polar 
body. 

In the young child the greater portion of the ovary is composed of 
the cortex, which is filled with large numbers of closely packed primor¬ 
dial follicles, those nearest the central portion of the ovary showing 
the most advanced stages of development. In young women the cortex 
still contains large numbers of primordial follicles separated by thicker 
bands of connective tissue, which is made up of cells with spindle- 
shaped or oval nuclei. Each primordial follicle consists of an oocyte 
and its surrounding single layer of flattened epithelium. The oocyte is 
a single large cell, more or less round in shape, with a clear protoplasm 
and a tolerably large nucleus occupying its central portion. The nucleus 
presents a marked reticulated network and at one point a well-defined 
nucleolus, as well as numerous accessory nucleoli, wdiich are formed at 
the intersections of the nuclear thread-work. 

According to Nagel, the oocyte remains constant in size from birth 
until the beginning of the transformation of the primordial into the 
typical graafian follicle, no matter at what period of life this change 
may occur. These primordial ova, or oocytes of the first order, measure 
from 48 to 69 microns, and their nuclei from 29 to 32 microns in diam¬ 
eter. The oocyte is surrounded by a single layer of small, spindle- 
shaped epithelial cells, which are somewhat sharply differentiated from 
the still smaller spindle-shaped cells of the surrounding stroma 
(Fig. 74). 

Occasionally a primordial ovum may contain two nuclei or germinal 
vesicles, as has been shown by Nagel, Klein, von Franque, and others. 
Again, occasionally two and sometimes three distinct ova may be found 



THE OVARIES 


71 




«*«> V 


in a. single primordial follicle, and it is from such structures that 
multiple pregnancies were formerly supposed to develop. 

When, under the influence of factors with which we are as yet un¬ 
acquainted, the primordial follicle begins to develop, we notice in the 
first place that its epi¬ 
thelium becomes converted 
into a single layer of 
cuboidal cells (Fig. 74). 

Nuclear figures soon make 
their appearance, and the 
cells begin to proliferate 
rapidly, so that in a very 
short time the ovum be¬ 
comes surrounded by a 
number of layers of epi¬ 
thelial cells. Certain of 
these cells undergo degen¬ 
eration, and vacuolated 
areas are not infrequently 

observed between them. This process continues until a considerable por¬ 
tion of the follicle is filled with fluid, which is formed partly by the 
degeneration of the follicular cells and partly by transudation from 
surrounding vessels. 

Coincident with the development of the fluid, the so-called liquor 
folliculi, the ovum becomes 
pushed to one side of the follicle, 
where it is surrounded by a mass 
of cells—the discus proligerus or 
rur 


Fig. 74. —Ovary of Young Woman, showing Pri¬ 
mordial Follicles on Left Side and Follicle 
just beginning to develop on Right. X 210. 




Ifk ji • 


/*» 

% m 



s 

k'v nm 

r%ii is ^ 


stmt*,, 


V, 5• • • s _ r - tJ '~ 




Fig. 75. —Developing 
X 210. 


Follicle. 



Fig. 76. —Developing Follicle. 


cumulus oophorus —while the rest of the epithelium is arranged in a 
number of layers around the interior of the follicle, and is known as the 
membrana granulosa (Fig. 77). 

While these changes are taking place, the ovum itself becomes larger, 
important changes take place in its nucleus preparatory to the formation 
of the first polar body, yolk granules, or deutoplasm, are deposited in its 

















72 


THE FEMALE ORGANS OF GENERATION 


protoplasm, and a thin, transparent structure—the zona pellucida—ap¬ 
pears about its periphery. At the same time, the stroma immediately 
surrounding the growing follicle becomes vascular, and its cells show 
marked evidences of proliferation. The membrana granulosa is sep¬ 
arated from the stroma by a thin basement membrane consisting of a 
single layer of flattened, spindle-shaped, connective-tissue cells. Just 
between the basement membrane and the outermost layer of the mem¬ 
brana granulosa there not infrequently appears a thin, transparent layer, 



Fig. 77.—Follicle Approaching Maturity. X 210. 

D., discus proligerus: M.G., membrana granulosa; T.ex , tunica externa; T.int ., 

tunica interna. 


which was first described by Grohe and Slavjansky. This, no less than 
the zona pellucida, is a species of exudate from the granulosa cells. 

Mature Graafian Follicle.—From birth until the cessation of sexual 
life, graafian follicles are constantly being developed. Before the age of 
puberty they are found only in the deeper portions of the cortex, and 
do not reach the surface of the ovary; later, however, they develop in the 
superficial portions of the cortex and make their way to the surface, 
where they appear as transparent vesicles, varying from a few to 10 or 
12 millimeters in diameter. As the follicle approaches the surface of 
the ovary its walls become thinner and more abundantly supplied with 
vessels, except in its most prominent projecting portion, which appears 






THE OVARIES 


73 


almost bloodless and is designated as the stigma, the spot where rupture 
is to occur. 

The mature graafian follicle consists of a connective-tissue covering 
—the theca folliculi; an epithelial lining—the membrana granulosa; 
the ovum, and the liquor folliculi. The theca folliculi is readily divided 
into two layers: an outer, the tunica externa, and an inner, the tunica 
interna. The tunica externa consists of the ordinary ovarian stroma, 
which is arranged concentrically about the follicle, while the connective- 
tissue cells of the tunica interna have undergone marked change. 

Almost as soon as the primordial follicle shows signs of development, 
nuclear figures appear in the stroma immediately surrounding it, and a 



Fig. 78.—Section through Wall of Mature Follicle (Highly magnified). 
M.G., membrana granulosa: T.I., tunica interna; T.E., tunica externa. 


considerable multiplication of cells occurs. These become considerably 
larger than the surrounding connective-tissue cells, and as the follicle in¬ 
creases in size assume a granular appearance, which is due to the presence 
of a yellowish pigment. These cells are designated as lutein cells and, 
as will be seen later, play an important part in the formation of the 
corpus luteum, as well as in the process of follicular atresia. In most 
hardened specimens the coloring matter has been dissolved out, and the 
cells appear not unlike those of the suprarenal capsules (see T. I., Fig. 
78). At the same time there is a marked increase in the vascularity of 
the theca, and numerous lymphatic spaces make their appearance. 

The epithelial lining of the follicle, or membrana granulosa, consists 
of a number of layers of small polygonal or cuboidal cells, with round, 
darkly staining nuclei, which are arranged in fewer layers the larger 
the follicle. At one point the membrana granulosa is much thicker 
than elsewhere, and forms a more or less pyramidal mound in which 








74 


THE FEMALE ORGANS OF GENERATION 


the ovum is included. This is the discus proligerus or oophorus, and 
is usually situated at the portion of the follicle farthest removed from 
the surface of the ovary (see Fig. 77). The follicle is filled with a clear, 
albuminous fluid, the liquor folliculi, which is partly the product of 
the degenerated follicular epithelium and partly a transudate from sur¬ 
rounding vessels. As the follicle approaches its highest development, 
its epithelium undergoes fatty degeneration, as can be demonstrated by 
appropriate technique. 

As the ovum approaches maturity, it becomes the largest cell in the 
body, and, according to Nagel, measures from 150 to 250 microns (1/5 



Fig. 79.— Mature Human Ovum. X 480. Carnegie Laboratory. 


millimeter) in diameter, as compared with 48 to 69 microns in its 

primordial condition; while Jackson estimates that it weighs 0.000004 
gram. 

II the neatly xnature ovum be examined in the liquor folliculi or in 
notmal salt solution, the following structures, may be distinguished in 
and about it: (a) a corona radiata; (5) a zona pellucida; (c) a perivi- 
telline space; ( d ) a small, clear zone of protoplasm; (e) a broad, finely 
gianulated zone of protoplasm; (/) a central, deutoplasmic zone; and 
(g) the germinal vesicle with its germinal spot. 

The corona radiata consists of a number of layers of follicular epithe¬ 
lium which adhere to the ovum, and was so designated by Bischoff, by 
whom it was first described. Inside of the corona radiata comes a nar- 
row, transparent zone the zona pcllucxda —which is a product of the 








THE OVARIES 


75 


granulosa cells, and does not belong to the ovum itself. Separating the 
ovum from the zona pellucida is a clear, narrow space, the perivitelline 
space, within which the ovum is freely movable, so that no matter what 
position it may assume its germinal vesicle will always point upward. 
Inside of the perivitelline space is the ovum proper, which differs from 
the primordial oocyte, not only by its increased size, but more especially 
by the presence of a yolk or deutoplasm, which fills the greater part of 
its interior. 

The deutoplasm occupies the central portion of the ovum, and is 
made up of large numbers of irregularly shaped, highly refractive gran¬ 
ules. As it develops it pushes the germinal vesicle to one side, so that 
the latter always assumes an eccentric position in the ovum. Outside of 
the deutoplasm comes a narrow zone of finely granular protoplasm, which 
owes its peculiar appearance to the presence of very small yolk-granules; 
external to this, again, is a still narrower zone of clear protoplasm. 

The nucleus or germinal vesicle presents a distinct reticular, nuclear 
network, the intersections of which appear as very darkly staining points. 
The nucleolus or germinal spot is much larger than in the primordial 
ovum, and according to Auerbach presents ameboid movements. 

An ovum presenting the above characteristics is generally described 
as mature, but is not capable of fertilization and further development 
until it has undergone certain changes, which are designated as matura¬ 
tion, and manifested by the formation and casting off of the polar 
bodies. 

Graafian follicles, as we have already pointed out, develop through¬ 
out childhood, and occasionally attain a considerable size; but they 
rarely rupture at this time on account of their position in the depths 
of the ovary and the intervention of a thick layer of cortex between them 
and the surface. In adults, on the other hand, the developing follicle 
makes its way to the surface, and when it has attained its highest 
development ruptures and extrudes its ovum into the peritoneal cavity 
or the tube, where it may be fertilized. 

Formerly it was believed that rupture of the follicle was brought 
about by the increased tension resulting from the rapid formation of the 
liquor folliculi. Clark, however, has shown that rupture of the follicle 
is a complex process, and is due primarily to circulatory changes. As 
the period of ovulation approaches, the ovary becomes engorged with 
blood and, the intra-ovarian tension being markedly increased, the grow¬ 
ing ovum is forced to the surface; at the same time the circulation in 
the most distended portion of the wall of the follicle is interfered with, 
whence results necrosis at the point designated as the stigma, which 
eventually gives w r ay. 

Corpus Luteum.—The corpus luteum is a structure which is formed 
at the site of a ruptured follicle. When the mature follicle ruptures, 
the ovum, liquor folliculi, and a considerable portion of the degenerated 
membrana granulosa make their escape, and the w r alls of the empty 
follicle collapse. In a short time, however, its cavity becomes filled 
with blood, which is derived partly from the vessels at the point of 
rupture, but principally from those of the tunica interna of the theca. 


76 THE FEMALE ORGANS OF GENERATION 

The corpus luteum,-therefore, in its earliest stages is simply a rup¬ 
tured follicle filled with blood, outside of which is a narrow \ellow ling 
formed by the so-called lutein cells. These, however, proliferate rap¬ 
idly and invade the blood-filled follicle, forming a festooned layer about 
its central blood clot (Fig. 80). This layer is yellowish in coloi, whence 
the term “corpus luteum.” As the structure becomes older, the yello\v 
ring becomes thicker and thicker, until at last it almost entirely fills 
the^interior of the follicle, the central blood clot remaining being now 
quite small. 

At its period of greatest development, namely, about 14 days after 
rupture, the corpus luteum is always larger than the original follicle, 



« 


C.F. 

Fig. 80.—Portion of Ovary, showing a Corpus Luteum of Pregnancy, with Cystic 

Center. X 4. 

B.C., blood clot; C.F., corpus fibrosum; F., graafian follicles; L.C., lutein cells. 


and occupies a considerable portion of the ovary, sometimes as much 
as one-third of the entire organ. 

Microscopic sections through a well-developed example show r that 
its center is occupied by a compressed blood clot, immediately outside 
of which is a thin layer of newly formed connective tissue. The greater 
part of the structure, however, is occupied by the festooned yellow' ring, 
which is made up of large, polygonal, epithelioid cells, w'ith small, 
round, somewhat faintly staining nuclei. These are the lutein cells , 
whose protoplasm has taken on a granular appearance due to the pres¬ 
ence of a peculiar yellow' pigment which is soluble in chloroform, 
alcohol, and ether. According to Escher, the pigment is chemically 
identical with carotin—the coloring matter found in carrots. Corner, 













THE OVARIES 


77 


who has carefully studied the cytology of the lutein cell in the pig, 
reports that it is unusually complicated. The layer of lutein cells is 
traversed by numerous radiate, tolerably thick, connective-tissue par¬ 
titions, to which it owes its festooned appearance. They are richly 
supplied with blood vessels and lymphatics (Fig. 81). 

As the cavity of the follicle is encroached upon by the growing 
lutein cells, the blood clot becomes more and more compressed, and 
vascular loops extend into it and soon cause its organization. At the 
same time, the blood pigment is removed by leukocytes, which can be 
found in the surrounding tissue with their bodies filled with particles 



Fig. 81.—Section through Yellow Layer of Corpus Luteum, showing Lutein Cells 


of it. Occasionally hemorrhage does not take place into the ruptured 
follicle, and a corpus luteum is formed without a central blood clot. 
This is the exception in human beings, but the rule in many of the 
lower animals. 

After the cavity of the follicle has become obliterated by the in¬ 
growth of the lutein cells and connective tissue, degenerative changes 
soon make their appearance in the former, some of which undergo 
hyaline, and others fatty, degeneration. In young women, in whom the 
circulation is active, the degenerated lutein cells are rapidly absorbed, 
so that in a short time the corpus luteum becomes replaced by newly 
formed connective tissue which corresponds closely in appearance to the 
surrounding ovarian stroma. But in more advanced life, vhen the 
ovarian circulation has become impaired, absorption goes on less rapidly; 
and not infrequently the degeneration extends to the intervening con¬ 
nective tissue and blood vessels until the entire structure is converted 
into an almost homogeneous mass of hyaline in which only a few con- 


78 


THE FEMALE ORGANS OF GENERATION 


nective-tissue cells and degenerated blood vessels can be seen (Fig. 82). 
These structures—the so-called corpora fibrosa or albicantia —present 
on fresh section a dull white appearance, somewhat suggestive of old 
scar tissue. They are, however, gradually invaded by the surrounding 





Fig. 82.—Corpus Fibrosum. X 75. 


stroma, and become broken up into smaller and smaller hyaline masses, 
which are eventually absorbed, the site of the original follicle being 
indicated only by an area of slightly thickened connective tissue. When 
the circulation is very defective, absorption takes place much more 

slowly, so that it is not 
uncommon to find the 
ovaries of women near 
the menopause almost 
filled by corpora fib 1 
rosa of varying size. 
Frequently the small 
hyaline bodies result¬ 
ing from the breaking 
up of these structures 
assume peculiar and 
bizarre forms, and 
very often present a 
curved and twisted ap¬ 
pearance suggestive of 
a degenerated artery 
(Fig. 83). Similar 

structures are sometimes left after the obliteration of non-ruptured 
follicles. 



Fig. 83.—Later Stage or Corpus Fibrosum. X 75. 


Practically all authorities are agreed as to the life-history of the 
corpus luteum, and the only point which still remains unsettled deals 
"with the ongin of the lutein cells. The earlier observers considered 
that the changes were analogous to the organization of a blood clot which 







THE OVARIES 


79 


was followed by the formation of cicatricial tissue, but at present this 
view possesses only an historical interest. 

Many investigators believe that the lutein cells are of connective- 
tissue origin and represent the cells of the theca interna. This view 
was first advanced by von Baer, and has been confirmed by the work 
of Kollicker, His, Beigel, Nagel, Clark, Waldeyer, Hegar, and many 
others. A number of more recent authors, on the other hand, following 
the example of Bischoif, consider that they originate from cells derived 
from the membrana granulosa. This explanation has been advocated 
more particularly by Sobotta, and has received additional support from 
the work of Marshall, Meyer, huge, Miller and others. These in¬ 
vestigators claim that immediately following the rupture of the follicle, 
the cells of the membrana granulosa, instead of being exfoliated as was 
previously taught, rapidly proliferate, soon fill the cavity, and become 
the true lutein cells. While they do not deny that the cells of the tunica 
interna of the theca undergo pronounced changes, they contend that 
they play no part in the production of the corpus luteum, and designate 
them as theca lutein cells, as contrasted with the granulosa lutein cells. 

Corner, on the other hand, in the sow and Evans in the rat believe 
that both types of cells are involved; and, while those derived from 
the membrana granulosa are at first more numerous, those derived from 
the theca persist for a longer period. 

Up to a few years ago, I was convinced of the connective-tissue 
origin of the lutein cell, and even now I am not prepared to admit that 
I was entirely in error, but the proof adduced by Corner is so strong 
that I am prepared to concede that the lutein cell may have a double 
origin, and be derived from the proliferating membrana granulosa, as 
well as from the theca. 

Strong support in favor of the connective-tissue origin of the lutein 
cell is to be obtained from the changes observed in the great majority 
of follicles, which degenerate in situ without rupture. This process 
has been studied by a number of observers, notably Slavjansky, Schott- 
lander, Clark, Stevens, Seitz and others, and is designated as follicular 
atresia. In such circumstances, precisely the same proliferation of theca 
cells is observed as in the formation of the corpus luteum, except that 
hemorrhage is absent and that the process is less pionouncod. After 
the follicle has attained a certain size, the ovum undergoes cytolysis and 
with the entire membrana granulosa is separated from the wall of the 
follicle, and lies free in its cavity, undergoing degenerative changes and 
eventual absorption, while the ceils of the theca are actively proliferating 
and are being converted into lutein-like cells. Eventually, the walls of 
the follicle collapse, the tissue composing it undergoes fatty and hyaline 
changes, so that later an irregularly twisted hyaline body results, which 
can not be distinguished from a similar structure derived from a corpus 

luteum, or even from a degenerated vessel. 

Moreover, the spontaneous involution of the large lutein cell cjsto- 
mata, which frequently accompany hydatidiform moles, would seem to 
offer additional evidence in favor of the connective-tissue origin of the 
cells in question. Were they epithelial, such an outcome would be un- 



80 


THE FEMALE ORGANS OF GENERATION 


likely, as epithelial cysts generally tend toward enlargement rather than 
retrogression. 

One function of the corpora lutea is to bring about the obliteration 
of the spaces left by the ruptured follicles without the formation of 
cicatricial tissue; for if they healed by the lalter process it is evident 
that in a very short time the entire ovary would be converted into a 
mass consisting of nothing but scar tissue, the very nature of which 
would effectually prevent further ovulation. It has been estimated by 
Clark that if each follicle healed in this manner, and if ovulation could 
continue under such conditions, a fibroma would eventually be produced 
3,000 times as large as the original ovary. 

Fraenkel, in 1903, advanced the theory that the chief function of the 
corpus luteum is to elaborate a secretion which regulates the blood supply 
of the uterus, and.thus controls the process of menstruation, as well 
as the formation of the decidua and the implantation of the ovum. He 
elaborated his theory in 1910 by numerous additional experiments upon 
rabbits, and some upon women. In the latter he found that the next 
succeeding menstrual period failed to occur when the corpus luteum 
had been destroyed by means of a cautery, which might readily be done 
without danger during the course of a simple operation, such as sus¬ 
pension of the uterus. FraenkeFs second contribution w^as very con¬ 
vincing, and, as has already been indicated, it is now generally believed 
that the structure should be regarded as a temporary gland of internal 
secretion. 

It would lead too far afield to discuss the voluminous literature 
upon the subject, and it must suffice to state that certain investigators 
have even gone so far as to claim that they have succeeded in isolating 
from the corpus luteum substances which produce a specific effect when 
injected into animals. Thus, Seitz and Wintz state that they have 
isolated from early and late corpora lutea of the cow, respectively, two 
substances possessing different physiological properties. From the 
former they obtained lipamin, which they claim causes swelling of the 
endometrium, and from the latter luteolipoid which checks bleeding. 

It is usual to distinguish between true and false corpora lutea—• 
namely, those following impregnation and menstruation respectively. 
This distinction is based entirely upon their relative size, and not upon 
any inherent anatomical difference, as they both present exactly the same 
structure, the larger size of the so-called true corpus luteum being simply 
due to the increased vascular supply incident to pregnancy. J. W. 
Miller stated in 1914 that the two varieties could be easily differentiated 
by histological and microchemical methods. He held that neutral fat 
could not be demonstrated in the corpus luteum of pregnancy until after 
delivery, but that areas of colloid and of calcification soon appear; 
while in the corpus luteum of menstruation fat is readily demonstrable, 
but colloid and calcification is absent. I have no experience with these 
criteria, but Corner has pointed out that in the sow fat is constantly 
present in the former. 

Not infrequently the corpus luteum of pregnancy contains in its 
center a small cyst filled with clear fluid, the walls of which are com- 



LITERATURE 


81 


posed of connective tissue, outside of which are the typical lutein cells. 
Such cysts are due to the liquefaction of the central blood clot (see 
Fig. 79). 

In rare instances the corpus luteum, instead of disappearing in the 
manner just described, may be the starting point of cystic formations, 
to which attention was first directed by Rokitansky, and with which 
every gynecologist is now familiar. 

The corpus luteum was first described by De Graaf as a conglomer¬ 
ate glandular body, and was considered by him and all earlier authori¬ 
ties as positive evidence of previous childbearing. Moreover, it was 
generally believed that the number of children which a woman had borne 
could readily be estimated by counting the number of corpora lutea in 
her ovaries. This view was held for many years, and was so firmly 
established, even at the end of the eighteenth century, that such eminent 
authorities as Abernethy, Sir Astley Cooper, and Denman had no hesi¬ 
tancy in swearing in a medicolegal case that a woman had been preg¬ 
nant because a corpus luteum was found in one ovary. Even after 
the more frequent performance of autopsies, and the closer attention 
directed to the condition of the ovaries had led to the abandonment 
of this view, it was for a time believed that the presence of corpora 
lutea indicated that the individual had indulged in sexual relations, or 
had at least been under marked sexual excitement. Finally, as a 
result of the work of Bischoff, Raciborski, Negrier, and Pouchet (1840- 
47), it was definitely established that a corpus luteum developed after 
each menstrual period in virginal as well as married women. For fuller 
information on this point the works of Montgomery and Dalton may 
be consulted. 


LITERATURE 

Abel and McIlroy. The Arrangement and Distribution of the Nerves in Certain 
Mammalian Ovaries. Proc. Roy. Soc. Med., 1913, vi, Obst. and Gyn. beet., 
240-247. 

Aime. Recherches sur les cellules interstitielles de 1 ’ovaire, etc. Arch, de Zoologie 
exp. et gen., 1907, 4me ser. vii, 95-113. 

Auerbach. Quoted by Nagel. 

Aschner. Die Blutdriisen-erkrankungen des Weibes. Wiesbaden, 1918. 
von Baer. De ovi mammalium et hominis genesi. Leipzig, 1827. 

Beigel. Zur Naturgeschiehte des Corpus luteum. Archiv f. Gyn., 1878, xiii, 109- 

122 . 

Bischoff. Entwickelungsgeschiehte der Saugethiere und des Menschen, 1842. 
Beweis der von der Begattung unabhangigen periodisclien Reifung und Los- 
losung der Eier als der ersten Bedingung ihrer Fortpflanzung, etc. Giessen, 

1844. 

Bouin. Les deux glands a secretion interne de 1 ’ovaire. Rev. med. de l’Est, 

1902. , . 

Chiari. Ueber Ovarialverdoppelung. Centralbl. f. allg. Path. u. path. Anat., 

1904, xv, 546-548. 

Clark. The Origin, Growth and Fate of the Corpus Luteum. Johns Hopkins 
Hospital Reports, 1898, vii, 181-220. 

The Origin, Development, and Regeneration of the Blood-vessels of the Ovary. 


82 


THE FEMALE ORGANS OF GENERATION 


Contributions to the Science of Medicine, by pupils of William H. Welch, 
1900, 593-676. 

Corner. On the Orgin of the Corpus Luteum of the Sow from both Granulosa and 
Theca Interna. Am. J. Anat., 1919, xxvi, 117-183. 

Cyclic Changes in the Ovaries and Uterus of the Sow. Publication 276, Carnegie 
Institution, 1921, 117-146. 

Cornil. Note sur l’histologie des corps jaunes de la femme. Annales de gyn. et 
d’obst., 1899, lii, 373-381. 

Dahl. Die Innervation der weiblichen Genitalien. Zeitschr. f. Geb. u. Gyn., 1916, 
lxxviii, 536-601. 

Dalton. On the Corpus Luteum of Menstruation and Pregnancy. Philadelphia, 
1851. 

Engstrom. Ueberzahlige Ovarien. Mittheil. der gyn. Klinik des Prof. Eng- 
strom, 1897, i, 55. 

Evans. The Rhythm of Gonadal Function with Special Reference to the Relations 
between Uterus and Ovary. Endocrinology and Metabolism, Barker, Hoskins 
and Mosenthal, 1922, ii, 573-599. 

Escher. Ueber den Farbstoff des Corpus luteum. Zeitschr. f. physiol. Chemie, 
1913, lxxxiii, 198. 

Farre. Uterus and Its Appendages. Todd’s Cyclopaedia of Anatomy and 
Physiology, 1858, Parts XLIX and L. 

Foulis. The Development of the Ova, etc., with Special Reference to the Origin 
and Development of the Follicular Epithelial Cells. Jour, of Anat. and 
Physiol., xiii. 

Frankel. Die Funktion des Corpus luteum. Archiv f. Gyn., 1903, lxviii, 438- 
545. 

Ueber die innere Sekretion des Ovariums. Zeitschr. f. Geb. u. Gyn., 1910, lxiv, 
426-437. 

Neue Experimente z. Funktion d. Corpus luteum. Archiv f. Gyn., 1910, xci, 
705-761. 

von Franque. Beschreibung einiger seltenen Eierstockspraparate. Zeitschr. f. 
Geb. u. Gyn., 1898, xxxix, 326-346. 

de Graaf, Regnerus. De mulierum organis generationi inservientibus tractatus 
novus, etc. Lugd., 1672. 

Grigorieff. Schwangerschaft bei der Transplantation der Eierstocke. Centralbl. 
f. Gyn., 1897, 663. 

Grohe. Ueber den Bau und das Wachstum des menschlichen Eierstockes, etc. 
Virchow’s Archiv, 1863, xxvi. 

Haggstrom. Zahlenmassige Analyse der Ovarien eines 22 jahrigen gesunden 
Weibes. Zentralbl. f. Gyn., 1921, No. 49. 

von Herff. Ueber den feineren Verlauf der Nerven im Eierstocke des Men- 
schens. Zeitschr. f. Geb. u. Gyn., 1892, xxiv, 289-308. 

Hegar. Studien z. Histogenese des Corpus luteum. Archiv f. Gyn 1910 xci 
530-545. 

His. Beobachtungen liber den Bau des Saugetliiere-Eierstockes. Archiv f. mikr. 
Anat., 1865, i. 

Klein. Ueber mehreiige Graaf ’sche Follikel beim Menschen. Miinchener med. 
Abhandlungen, 1893, IV. Reihe, Heft 4. 

Knauer. Die Ovarient.ransplantation. Archiv f. Gyn., 1900, lx, 322-376. 

Kollicker. Entwickelungsgeschichte des Menschen und der hoheren Thiere. II. 
Aufl., Leipzig, 1879. 

Lipschutz. Die Pubertatsdriise und ihre Wirkungen. Bern, 1919 . 

Limon. Etude histologique et histogenetique de la glande interstitielle de l’ovaire. 
Th&se de Nancy, 1901. 



LITERATURE 


83 


McIlroy. The Development of the Germ Cells in the Mammalian Ovary. Proc. 

Royal Soc. Edinburgh, 1910, xxxi, 151-178. 

Mandl und Burger. Die biologische Bedeutung der Eierstocke. Wien, 1904. 
Marshall. On the Results of Heteroplastic Ovarian Transplantation. C^uart. J. 
Exp. Physiol., 1908, i, 115-120. 

Physiology of Reproduction. London, 1910. 

Martin. Ovarian Transplantation. Surg. Gyn. & Obst., 1922, xxxv, 573-585. 
Meyer. Ueber Corpus luteum-Bildung beim Menschen. Archiv f. Gyn., 1911, 
xciii, 354-404. 

Ueber die Beziehung der Eizelle zum Follikelapparat, etc. Archiv f. Gyn., 
1913, c, 1-19. 

Ein Mahnwort zum Kapitel ‘ ‘ Interstitielle Druse.* ’ Zentralbl. f. Gyn., 
1921, 593-601. 

Miller. Corpus Luteum, Menstruation u. Graviditat. Archiv f. Gyn., 1914, ci, 
568-620. 

Montgomery. An Exposition of the Signs and Symptoms of Pregnancy. 2d ed., 
London, 1863, 419-489. 

Morris. A case of Heteroplastic Ovarian Grafting, Followed by Pregnancy and 
the Delivery of a Living Child. Medical Record, May 5, 1906. 

Nagel. Das menschliche Ei. Arch. f. mikr. Anat., xxxi. 

Die weiblichen Geschlechtsorgane. Jena, 1896. 

Negrier. Recherches anatomiques et physiologiques sur les ovaries dans l’espece 
humaine. Paris, 1840. 

Pfluger. Ueber die Eierstocke der Saugethiere und des Menschen. Leipzig, 
1867. 

Pouchet. Theorie positive de 1 ’ovulation spontanee et de la fecondation, etc. 
Paris, 1847. , 

Purkyne. Symbolse ad ovi avium historiam ante incubationem. Lipsise, 
1830. 

Raciborski. De la puberte et de l’age critique chez la femme, et de la ponte 
periodique chez les mammiferes. Paris, 1844. 

Rokitansky. Ueber Abnormitaten des Corpus luteum. Allg. Wiener med. 
Zeitung, 1859, iv, Nr. 34, 35. 

Rouget. Recherches sur les organes erectiles de la femme, etc. Jour, de la 
physiol., 1858, i. 

Ruge. Ueber Ovulation, Corpus luteum u. Menstruation. Archiv f. Gyn., 1913, 
c, 20-48. 

Schaeffer. Vergleichend histologische Untersuchungen iiber die interstitielle 
Eierstocksdriise. Archiv f. Gyn., 1911, xciv, 491-541. 

Schottlander. Ueber den Graaf ’schen Follikel, etc. Archiv f. mikr. Anat., xxxi, 

219-294. 

Seitz. Ueberzahlige u. accessorische Ovarien. Volkmann's Sammlung klin. \ or- 
trage, 1900, Nr. 286. 

Seitz. Primat der Eizelle etc. Archiv f. Gyn., 1922, cxv, 1-14. 

Seitz u. Wintz. Ueber die Beziehungen des Corpus luteum zur Menstruation. 

Monatssclir. f. Geb.u. Gyn., 1919, xlix, 1-23. 

Skrobansky. Beitrage zur Kenntniss der Oogenese bei Saugetieren. Archiv f. 

mikr. Anat., 1903, lxii, 697-768. 

Slavjansky. Zur normalen u. path. Histologie der Graaf schen Bltischen des 
Menschen. Virchow’s Archiv, 1870, li. 

Sobotta. Ueber die Bildung des Corpus luteum bei der Maus. Archiv f. mikr. 
Anat., 1S97, xlvii. 

Entstehung des Corpus luteum der Saugetiere. Ergebnisse der Anat. u. Ent- 
wickelungsgeschichte, 1901, xl. 


84 


THE FEMALE ORGANS OF GENERATION 


Stevens. The Fate of the Ovum and Graafian Follicle in Premenstrual Life. 

Jour. Obst. and Gyn. B.rit. Empire, 1904, v. 1-12. 

Thumin. Ueberziihlige Eierstocke. Archiv f. Gyn., 1898, lvi, 342-354. 

Valentin. Handbuch der Entwickelungsgeschichte des Menschen. Berlin, 1835. 
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Waldeyer. Eierstock und Ei. Leipzig, 1870. 

Beitrage zur Kenntniss der Lage der weiblichen Beckenorgane. Bonn, 1892. 

Die Geschlechtszellen. Hertwig’s Handbuch der Entwickelungslehre, 1903, Bd. 
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Theil II, 790-804. 

Wallart. Studien liber die Nerven des Eierstocks, etc. Zeitschr. f. Geb. u. 
Gyn., 1915, lxxvi, 321, 368. 

Wendeler. Entwickelungsgeschichte und Physiologie der Eierstocke. Martin’s 
Die Krankheiten des Eierstocks u. Nebeneierstocks, Leipzig, 1899, 16-105. 
Williams. Papillomatous Tumours of the Ovary. Johns Hopkins Hospital 
Reports, 1892, iii, 1-84. 

Winiwarter. Recherches sur l’ovogenese et 1’organogenese de l’ovaire des mam- 
miferes. Archives de biologie, 1901, xvii, 33-199. 

Winterhalter. Ein sympathisches Ganglion im menschlichen Ovarium. Archiv 
f. Gyn., 1896, li, 49-55. 


SECTION II 

PHYSIOLOGY AND DEVELOPMENT OF THE OVUM 


CHAPTER III 

MENSTRUATION AND OVULATION—MIGRATION OF THE OVUM AND 
PLACE OF MEETING OF OVA AND SPERMATOZOA 


Menstruation.—By menstruation we understand one of the manifesta¬ 
tions of the cyclic process associated with ovulation, which is charac¬ 
terized by a discharge of blood from the genitalia, and which recurs at v 
regular intervals, except during pregnancy and lactation, from the time 
of puberty until the menopause. Ordinarily it comes on every four 
weeks and lasts from three to five days, though there are marked in¬ 
dividual variations as to its frequency and duration. 

The age at which the menses are established varies in different coun¬ 
tries, being earlier in warm and later in cold climates. In the tem¬ 
perate zone the first menstruation does not usually occur before the 
fourteenth or fifteenth year. Not a few instances of a much earlier ap¬ 
pearance of the function, however, are to be found in the literature, and 
are usually associated with precocious sexual development. One of the 
most notable cases of this character is that of Anna Mummenthaler, 
who, according to Haller, menstruated regularly from her second year, 
and gave birth to a full-term child at the age of nine. 

Frequently a bloody vaginal discharge is observed in new-born in¬ 
fants, which ceases after a few days, no further discharge occurring 
until puberty. To describe these as instances of precocious menstrua¬ 
tion, however, would be incorrect; more particularly as Halban at¬ 
tributes the loss of blood, as well as the occurrence of milk in the breasts 
of infants, to the circulation of a hormone probably derived from the 
placenta. 

In this country the menopause usually occurs about the forty-fifth 
year. In rare instances, however, the menstrual flow may cease as 
early as the twenty-eighth or thirtieth year, while occasionally it con¬ 
tinues until well into the fifties, or even until a later period. r I hus, 
Kennedy reported the case of a woman who gave birth to her twenty- 
second child when she was sixty-three years old, after which she still 
continued to menstruate. For various interesting historical and ethno¬ 
logical data concerning menstruation, the reader is referred to the monu¬ 
mental work of Ploss. 

The menstrual flow is derived from the uterine mucosa, and consists 

85 * * 



86 


MENSTRUATION AND OVULATION 


of blood mixed with mucus, which, in ordinary circumstances, does not 
coagulate. It contains fewer red cells and more lymphocytes than the 
circulating blood, and according to Schickele, and Stickel and Zondek 
the absence of coagulation is due to substances formed in the uterine 
tissues, as the fluid expressed from the uterus under high pressure in¬ 
hibits coagulation when added to normal blood. Moreover, Bell has 
shown that the menstrual discharge is rich in calcium, while at the same 
time its amount in the circulating blood is diminished. It also con¬ 
tains some toxic substance, whose nature is as vet unknown. Attention 
was directed to this fact by Schick in 1920, who demonstrated that con¬ 
tact with a menstruating woman would cause flowers to wither promptly, 
whereas controls retained their freshness. In our pharmacological 
laboratory this observation has been confirmed by Macht, who has further 
demonstrated that the phenomenon is due to the presence of a toxic 
substance. He found that the legume, lupinus albus, would sprout 
luxuriantly when placed in a vessel of water, but that the addition of 
a few drops of menstrual blood would result in a striking inhibition of 
growth. 

Hoppe-Seiler states that the quantity of blood lost at each menstrual 
period is greatly overestimated and rarely exceeds 37 cubic centimeters; 
while according to Labille the amount varies between 20 and 65 cubic 
centimeters. The former arrived at his conclusion hy soaking in water 
all the napkins used by the woman during a single period, and deter¬ 
mining the amount of hemoglobin in the solution, and the latter by 
determining the quantity of iron in the effused blood. 

Anatomical Changes in Menstruation.—Until recently, the statements 
concerning the extent of the changes occurring in the endometrium during 
menstruation were very contradictory. Sir John Williams believed that 
the entire mucosa was cast off at each menstrual period, while Moericke 
and numerous other observers stated that there was little or no de¬ 
struction of tissue. Between these extremes we find a number of authors 
stating that a greater or lesser portion undergoes disintegration. Gen¬ 
erally speaking, the older authorities held that the entire mucosa, or at 
least a considerable part of it, was cast off. 

In 1882, Moericke stated that menstruation was accompanied hy 
little or no destruction of tissue, hasing his statements upon the exami¬ 
nation of 45 specimens of the menstruating endometrium which he 
obtained by curettage. His views were soon confirmed by other observers, 
among whom may he mentioned De Sinety, Strassmann, Gebhard, and 
Findley; while Kahlden and Christ believed that the destruction was 
always considerable. 

These statements were made before the important contributions of 
Hitschmann and Adler in 1908 had revolutionized our ideas concerning 
the structure of the endometrium. Prior to that time it was gen¬ 
erally considered to be a thin membrane of relatively stable structure, 
and that the changes at the time of menstruation consisted in a certain 
amount of thickening and hyperemia, followed by the escape of blood 
into the uterine cavity, partly by diapedesis and partly by the rupture 
of distended capillaries. 


Ill 



SECTION THROUGH ENDOMETRIUM ON THIRD DAY OF MENSTRUATION. 

X 52. 

B., blood; B. G., gland filled with blood; Ep., surface epithelium; G., hypertrophied glands; 

S ., stroma. 



















ANATOMICAL CHANGES IN MENSTRUATION 


87 


The investigations of Hitschmann and Adler, which have in great 
part been substantiated by all subsequent observers, and particularly bv 
II. Schroeder, show that the process is not so simple, hut that the en¬ 
dometrium is undergoing constant change either in anticipation of or 
in recovery from the menstrual flow. This series of changes is desig¬ 
nated as the menstrual cycle, and consists of four phases: menstruation, 
regeneration, interval and premenstrual swelling. It is only in the 
last stages of the period of regeneration and the first part of the interval 
I that the endometrium presents the histological structure which was 
formerly described as normal—namely, a thin mucous membrane with 
simple tuhlilauglands. In the later part of the interval the endometrium 
begins to show distinct evidences of proliferation and soon passes into 
the state of premenstrual swelling, or the secretory phase. During this 
period, as the result of changes in both the stroma and glands, it be¬ 
comes several times thicker than before, and presents the histological 




Fig. 84— Normal Endometrium. Interval or resting stage. 

B, glands cut obliquely. X 30. 


B 

A, glands cut transverely; 


picture which was formerly considered characteristic of the so-called 
glandular endometritis. The stroma cells lose their oval shape and 
become round or polygonal in outline, and approach the decidual cell in 
appearance. At the same time the glands undergo marked hyperplasia, - 
associated with an increase in the size of the lumina and the develop¬ 
ment of projections from their walls, thereby assuming a twisted and 
corkscrewlike appearance. The individual epithelial cells become some- \ 
what larger and develop a marked secretory activity, so that upon 
appropriate staining the lumina are found to be filled by secreted ma¬ 
terial, which was absent in the earlier phases of the cycle. There is also 
a marked increase in vascularity, and distended capillaries appear in the 
superficial layers. After this phase has existed for a number of days, 
blood escapes into the superficial layers and makes its way into the 
uterine cavity, whence it escapes as the menstrual flow. Following the 
escape of blood, the endometrium becomes much thinner and regen¬ 
erative processes commence, even before the flow has ceased (Figs. 84 
to 8b). 









88 


MENSTRUATION AND OVULATION 




vV- % 

pI#! 


. 








Schroeder believes that menstruation is always associated with con¬ 
siderable destruction of tissue, so that in many instances only the 
deepest layers of the mucosa, which are in contact with the muscularis, 
are retained. In my experience, however, such is not always the case, 
and Plate III, which represents the endometrium from a uterus removed 
on the third day of menstruation, shows very distinctly that but little 
destruction of tissue has occurred. 

It accordingly appears that in the period of premenstrual swelling 
the endometrium becomes transformed into a relativelv thick membrane, 
which is indistinguishable from the decidua vera as seen in very early 
pregnancy. Indeed, the likeness is so striking that not a few investi¬ 
gators employ the same terms in describing it. and distinguish a super¬ 
ficial compact and a deeper spongy 
layer. Consequently it is assumed 
that the object of the premenstrual 
swelling is to prepare a suitable 
nidus for the reception and implan¬ 
tation of the fertilized ovum, and 


Fig. 85.—Normal Endometrium. 
Early Premenstrual Period. X 30 . 


Fig. 86.—Normal Endometrium. 
Advanced Premenstrual Period. X 30 . 


that menstruation sets in in case it fails to occur. For this reason, Evans 
and others suggest that it would be more appropriate to designate this 
part of the cycle as the pre-gravid rather than the premenstrual stage. 
Evidence in favor of such a view is afforded by the observation of 








RELATION BETWEEN MENSTRUATION AND OVULATION 89 

Wegelin and Aschheim that large quantities of glycogen appear during 
the premenstrual period and practically disappear after the flow, in¬ 
dicating that it was stored to aid in the nutrition of the ovum, and 
disappears if implantation fails to occur. 

We are still profoundly ignorant of the ultimate cause of menstrua¬ 
tion, although, as will be indicated in the following section, many authors 
associate it with degenerative changes in the corpus luteum. The re¬ 
seal dies of Schickele, and of Frankl and Aschner, however, may give 
a clue as to the mechanism by which it is effected. The former has 
shown that a substance can be expressed from the uterine tissue which 
possess the property of lowering the blood pressure and of dilating capil¬ 
laries; while the latter investigators have demonstrated the development 
of a tryptic ferment during the premenstrual phase, and it is possible 
that both of these factors may be implicated in the production of the 
bleeding. 

Relation between Menstruation and Ovulation.—By ovulation we 
understand the rupture of a mature graafian follicle and the extrusion 
of the ovum. The relation between menstruation and ovulation has 
given rise to a great deal of controversy, and, while many interesting 
facts have been added to our information, it must be conceded that the 
subject is still far from being satisfactorily understood. 

On the other hand, numerous investigations upon certain of the 
lower animals prove beyond question that a cycle of changes is con¬ 
stantly occurring in both the ovaries and uterus, which correlate the 
structure of the uterine mucosa to the various phases of ovarian activity, 
so that the animal goes into oestrus just about when the mature follicle 
is ready to rupture, with the result that the fertilized ovum descends 
into a uterus already prepared for its reception and offering the most 
favorable conditions for its implantation. Such investigations have been 
made in the dog by Marshall and Hainan, in the sow by Corner, in 
Dasyurus by Hill and O’Donoghue, in the guinea pig by Stockard and 
Papanicolaou and in the rat by Long and Evans. While their results 
vary in minor details, they all agree in establishing a definite oestrus 
cycle in which the ovarian and uterine changes are wonderfully cor¬ 
related, and indicate A corpus luteum plays a controlling part in 
bringing about th< define reaction. For these reasons it seems per¬ 
missible to conclud let o ; s in the lower animals is not comparable 
with menstruation v or i, hut that it probably corresponds with the 
early days of the riod emenstrual or pregravid swelling of the 

endometrium. 

Furthermore, t w : reL- of Stockard, and Evans and Long, in 
the guinea pig ami ctively, as well as the unpublished in¬ 
vestigations of Cc t monkey, demonstrate that the cyclical 

changes are not lir h I •: > th varies and uterus, but involve the vagina 
as well; so that f ■ ut e animation of the vaginal secretion makes 
possible the recog oi series of cyclical changes in its cellular 

content, which are \iara ' istic as to enable the trained observer to 

predict the condition e in the ovaries and uterus, and to confirm 

them upon killing tl ■ a 






90 


MENSTRUATION AND OVULATION 




Furthermore, the demonstration of hypertrophic changes in the mam¬ 
mary glands of many animals following ovulation, without the occurrence 
of pregnancy, and more particularly the changes in structure of the 
brood pouch in marsupials, which have been demonstrated by Hill and 
O’Donoghue, indicate that the process is more than local, and must be 
associated with the circulation of some hormonic substance. 

The fact that young girls can not usually conceive until after the 
appearances of the menses, and the extreme rarity of impregnation after 
their cessation, rendered it natural for the earlier observers to suppose 
that conception could not occur without menstruation, and that the men¬ 
strual flow represented the female semen. This view, however, was soon 
abandoned, and the discharge came to be regarded as a process of 
purification. 

It was not until the doctrine of periodical ovulation had been estab¬ 
lished by the work of Gendrin, Negrier, Bischoif, Pouchet, and others 
that definite ideas could be formulated concerning the relation between 
ovulation and menstruation. From then on, however, it has generally 
been believed that menstruation was brought about by the ripening of 
the graafian follicle, and that the two processes occurred almost, if not 
quite, simultaneously. 

This doctrine culminated in 1865 with appearance of PfliigePs 
article, in which he stated that the menstrual flow resulted from a reflex 
stimulation, which owed its origin to the pressure exerted by the grow¬ 
ing follicle upon the nerves of the ovary. This theory obtained almost 
immediate acceptance, and for years was the predominant belief; upon 
it was based our method of calculating the expected date of confinement, 
the rule being to date the beginning of pregnancy from the last menstrual 
period. 

Pfliiger’s theory, however, was somewhat shaken by the work of 
Leopold and his coworkers, whose careful studies of the condition of 
ovaries removed at operation proved conclusively that the two processes 
were not necessarily synchronous, and accordingly ovulation could not be 
considered the unvarying cause of menstruation. Clinical experience 
also lent further probability to this view, since it has shown that 
ovulation and subsequent pregnancy may take place without menstrua¬ 
tion; as is demonstrated by the instances of conception occurring before 
the establishment of menstruation or after the menopause, as well as 
during lactation, when the menstrual flow is usually absent. More¬ 
over, cases are recorded in which pregnancies had followed in such 
rapid succession that menstruation did not occur for years. 

Sigismund, Lowenhardt, Lowenthal, and Aveling next advocated 
the theory that ovulation preceded menstruation, and that the latter was 
due to the failure of conception. Aveling designated the process as 
nidation and denidation, and considered that a menstrual decidua was 
formed each month for the reception of the fertilized ovum, and that 
if conception did not occur it degenerated and was cast off with the 
menstrual flow. The gist of these theories was tersely expressed by 
Powers in the dictum, “Women menstruate because they do not con¬ 


ceive. 















RELATION BETWEEN MENSTRUATION AND OVULATION 91 

This view was also adopted by His and most embryologists as true, 
or a certain number of cases at least. They found on examining ova 
Inch were nominally of the same age, as estimated from the last 
jaenstrual period, that some presented a stage of development several 
ireeks in advance of the others. They held, therefore, that this differ- 
nce could be explained only by supposing that the former resulted 
rom conception soon after the last menstrual period, and the latter 
rom conception shortly before the first period missed. That ovulation 
ind menstruation are not synchronous is also confirmed by the reproduc- 
ive history of the orthodox Jewesses, noted for their fertility. Accord- 
ng to the Mosaic law women are considered unclean during the entire 
nenstrual period and the seven days following it, so that in them con¬ 
ception must occur after that time. This view also seems to receive 
support from my experience that practically three-fifths of the women 
vho marry in the middle of an intermenstrual period, and who miss 
;he succeeding flow, are delivered of children of normal size 280 days 
lfter the onset of the last period, or in less than nine calendar months 
ifter marriage. Somewhat similar conclusions were drawn by Siegel 
ind others, who studied the conditions in German women who con- 
leived after a visit from the husband who left the army on a short 
furlough, although striking exceptions were sometimes noted. 

Fraenkel stated that menstruation was due to the elaboration of an 
internal secretion by the corpus luteum, which he believed regulates 
the blood supply of the uterus. In 1910 he still further elaborated 
this view, and concluded that ovulation usually occurs 19 days after 
the first day of the last period; as he held that the corpus luteum result¬ 
ing from the rupture of that follicle attains its highst development 
during the following week, when, if conception does not occur, it under¬ 
goes rapid degeneration, and gives rise to menstruation. 

This belief has almost been converted into a certainty by the work 
of Halban, Meyer, Ruge, and It. Schroeder, in which the cyclical changes 
of the endometrium were studied in association with the development of 
the corpus luteum. As a result, these investigators conclude that o\ illa¬ 
tion usually occurs in the later days of the second week follow ing the 
beginning of the last period, and is immediately followed by the rapid 
development of the corpus luteum, which attains its highest perfection 
ten or twelve days later. If fertilization takes place, the corpus luteum 
persists practically unchanged for months, when its secretion plays an 
important part in the woman’s economy and probably regulates the 
implantation of the ovum. Whereas, if conception and implantation do 
not occur the corpus luteum promptly shows degenerative changes, which 
in turn lead to the onset of the menstrual flow. Or, to use Meyers 
terse expression—“without ovulation no formation of corpus luteum, and 

without the latter no menstruation.’’ 

From the evidence before us, we must conclude that ovulation 

usually occurs shortly before the middle of the intermenstrual period, 
and is followed twelve or fourteen days later by the menstrual flow r . In 
other words, menstruation is dependent upon the presence of the ovaries, 
and can not occur without ovulation. Moreover, it is probably in- 










92 


MENSTRUATION AND OVULATION 


augur at ed by the degeneration of the corpus iuteum, which originated 
after the rupture of a follicle during the intermenstrual period directly j 
preceding the flow. The figures just mentioned should not be regarded 
as absolute, as there is evidence that under certain conditions ovulation 
may occur at any time. Indeed, this has happened so frequently in the 
experience of Schickele that he is unable to regard it as a cyclic process. 
Notwithstanding such exceptions, the present view concerning the re¬ 
lations between ovulation and menstruation indicates that the optimum 
time for the occurrence of conception is about the middle of the inter- 
menstrual period, and not just before or just after the flow, as is gen¬ 
erally believed. In any event, the old teaching that menstruation and 
ovulation are synchronous must be abandoned. 

The results following various operations upon the genital tract show 
that menstruation is dependent upon the presence of the ovaries, but 
that ovulation may take place without the presence of the uterus; as it 



Fig. 87. —Diagram Illustrating Menstrual Cycle (Evans). 


is generally admitted that the complete removal of both ovaries, which 
necessarily stops ovulation, is always associated with cessation of the 
menses. On the other hand, the total removal of the uterus, while 
associated with abolition of the menstrual flow, exerts no effect upon 
ovulation, as is manifested by the regular occurrence of the so-called 
menstrual molimina. 

A number of observers have attempted m show that menstruation 
may occur independently of ovulation, basing their contention upon the 
occasional continuance of menstruation after the removal of the ovaries. 
This conclusion, however, is fallacious, as in such cases either the ovaries 
had not been completely removed, or an accessory ovary w r as present. 
The now well-established fact that a very small portion of ovary will 
suffice for ovulation has been demonstrated by the occurrence, in rare 
instances, of pregnancy after the supposed removal of both ovaries by 
competent operators, cases of which have been reported by Gordon, 
Meredith, and others. 

Mary Putnam Jacobi, in 1876, advanced the so-called menstrual- 
wave theory, which has been accepted by Stephenson, Webster, Ott, Van 








































MIGRATION OF THE OVUM 


93 


! ie Velde, and others. According to this idea, the metabolic processes 
in women present a distinct rhythm, and gradually increase in intensity 
up to the time of the menstrual flow, when they suddenly drop and 
reach their lowest point; after this they gradually rise again to attain 
their maximum intensity just before the next menstrual period, thus 
indicating that the entire process is under some central control, and is de- 

I pendent upon some general and as yet unknown cause. 

Ordinarily, the fallopian tubes take no part in the menstrual func¬ 
tion, and in none of my specimens were there any traces of a bloody 
fluid in them. Occasionally, however, the tubal mucosa may share in 
the process, as has been shown by Thompson, who reported a case in 
which a pyosalpinx had ruptured through the abdominal wall, leaving 
a fistulous opening. Through this fistulous opening a slight amount 
of bloody fluid exuded at each menstrual period. Jagerroos, on the 
contrary, stated that the involvement of the tubal mucosa occurs only 
in inflammatory conditions and is absent in normal tubes. The latter, 
however, show distinct cyclical changes both in the epithelium and 
connective tissue. 

Migration of the Ovum.— The mechanism by which the ovum gains 
access to the tube after escaping from the ruptured follicle is a ques¬ 
tion of extreme interest, and one which has given rise to a great deal 
of discussion. The process is readily understood in those animals in 
which the ovaries are completely inclosed in a peritoneal sac into which 
the tube opens; but in women, and in animals in which the ovary 
projects freely into the peritoneal cavity, the question presents greater 
difficulties and has not as yet received a thoroughly satisfactory solution. 

As we have already shown, the fimbriated extremity of the tube lies 
in the neighborhood of the ovary, hut is not necessarily in direct contact 
with it, the only organic connection between the two structures being 
I furnished by the fimbria ovarica, which is attached to the upper or tubal 
pole of the ovary. 

Numerous theories have been advanced to explain the manner in 
which the ovum enters the tube. Rouget believed that the latter became 
engorged with blood at the menstrual period, and that, as a result of its 
becoming erectile, the fimbriae applied themselves to the portion of the 
ovary in which the ripe follicle was situated—so that, after its rupture, 
the ovum was immediately taken up by the fimbriated extremity of 
the tube. This view, however, has been abandoned, as it is difficult 
to suppose that the tube could instinctively pick out the exact portion 
of the ovary to which it should apply itself. Kehrer believed that the 
ovum was ejected from the follicle at the time of rupture with sufficient 
force to be thrown directly into the fimbriated end of the tube. This, 
the so-calle(J; ejaculation, theory for a time enjoyed considerable vogue, 
but has likewise been abandoned. 

At present it is generally believed that the cilia upon the fimbriated 
end of the tube give rise to a current in the capillary layer of fluid 
which lies between the various pelvic organs, so that the ovum, on 
escaping from the follicle, is taken up by the current and wafted toward 
one or the other tube, vdience it is carried to the uterus. I he coriectness 







94 


MENSTRUATION AND OVULATION 


of this view has been substantiated by the experimental work ol Pin¬ 
ner, Jani, and Lode. The former injected cinnabar and the latter the 
ova of ascarides into the peritoneal cavity of animals, and found that 
they made their way to the pelvis, where they were taken up by the 
tubes, through which they were carried to the uterus, and eventually 
appeared in the vagina. It is more than likely, however, that a con¬ 
siderable proportion of the ova which escape from ruptured follicles fail 
to gain access to the tubes, and perish in the peritoneal cavity. 

In 1844 Bischotf directed attention to the fact that in animals pos¬ 
sessing bicornuate uteri one frequently finds that the corpora lutea are 
in one ovary, while the embryos are developed in the uterine horn on 
the opposite side. He supposed in such cases that the fertilized ova 
had come from the ovary in which the corpora lutea were found, and 
had made their way into the cornu of the opposite side, instead of into 
the one corresponding to the ovary from which they came. This process 
he designated as migration of the ovum. 

The possibility of such an occurrence in women was first carefully 
studied by Kussmaul, who stated that it might be brought about in two 
ways: either by the ovum making a circuit through the pelvic cavity 
and thus gaining access to the opposite tube, or passing down one tube, 
traversing the uterine cavity, and then making its way up the opposite 
tube. The former he designated as external, the latter as internal, 
migration of the ovum. 

External migration of the ovum is frequently observed, whereas 
there is grave doubt as to the possibility of the occurrence of internal 
migration in women. We are unable to ascertain how frequently external 
migration takes place in normal uterine pregnancies, though it is prob¬ 
ably much more common than is generally believed. Its occurrence has 
been repeatedly demonstrated in cases of bicornuate uteri, and those 
presenting a rudimentary horn; and frequently in normal uteri, when 
the fimbriated extremity of one tube is occluded, as in cases of hydro¬ 
salpinx or inflammatory lesions, while that of the other tube is patent. 
In such cases, when the corpus luteum is found on the side of the diseased 
tube, it is inferred that the ovum had gained access to the uterus 
through the normal or only slightly diseased tube of the opposite side. 

External migration of the ovum has been produced experimentally 
in animals by Leopold, who excised one ovary and the opposite tube, and 
found in a number of such cases that the animals became pregnant after 
the operation. A very convincing case has been reported by Kelly, 
who removed the diseased left ovary and right tube from a patient, 
leaving the normal right ovary and left tube behind. Fifteen months 
later she was delivered at term, and seventeen months subsequently 
the remaining tube was removed for a ruptured extra-uterine pregnancy. 

I have examined numerous specimens of extra-uterine pregnancy, 
which apparently offered incontrovertible evidence of external migration 
of the ovum, the corpus luteum being found in the ovary of one side 
and the pregnancy in the opposite tube. The phenomenon was beauti¬ 
fully exemplified in a specimen which Dr. H. C. Coe sent me for 
examination. In this case the right tube had twice been the seat of 





PLACE OF MEETING OF THE OVUM AND SPERMATOZOA 


95 


i 

extra-uterine pregnancy. The first pregnancy, which dated from several 
years before, was situated in the isthmic portion of the tube, the 
foetus having become converted into a lithopedion which completely 
blocked the lumen. External to this, and occupying the lateral portion 
of the tube, was a freshly ruptured four months' pregnancy. The corre¬ 
sponding ovary was small, atrophic, covered by adhesions; the opposite 
one contained the corpus luteum of pregnancy. Apparently in this 
case the ovum must have been fertilized, soon after leaving the left 
ovary, by a spermatozoon which had made its way up the left tube; 
after which it had been carried to the right tube and had passed down it 
until arrested by the lithopedion, when it underwent further develop¬ 
ment. 


A\ liile no satisfactory evidence in favor of the occurrence of internal 
migration has been adduced for women, Corner has demonstrated its 
possibility in sows, by showing that the number of embryos in the two 
horns of the uterus is not necessarily the same as the number of corpora 
lutea in the corresponding ovary. For example, if four embryos are 
found in either horn, while the right ovary contains two and the left 
six corpora lutea, he assumes that the right horn originally contained 
two and the left horn six embryos, but that as they grew larger two 
embryos were forced mechanically from the left to the right horn. 

Place of Meeting of the Ovum and Spermatozoa.—During coitus the 
semen is deposited in the vagina, and the question arises, How do the 
spermatozoa contained in it make their way into the uterus, and when 
and where do they come in contact with the ovum? 

The number of spermatozoa contained in a single ejaculation is mar¬ 
velous, and has been estimated by Lode at 226,257,900. Various ex¬ 
planations of the method by which they gain access to the uterine 
cavity have been advanced, the most widely known being the aspiration 
theory of Litzmann, Wernich, and Beck, and the mucus-plug theory of 
Kristeller. The first-mentioned observers held that the external mus¬ 
cles of the uterus contract forcibly during coitus and compress the 
uterine cavity, into which the spermatozoa are aspirated when relaxa¬ 
tion occurs. Kristeller believed that at the height of the orgasm the 
thick tenacious mucus, which is usually found in the cervix, is forced 
down for a short distance into the vagina, where it becomes covered 
with spermatozoa, after which it returns to its original position and 
carries them with it. 

It cannot be denied that spermatozoa may gain access to the uterine 
cavity in either of these ways in a certain number of cases; but in 
the majority of instances it is probable that they make their way 
thither by their own activity. Moreover, the observations of Low indi¬ 
cate that the mucous secretion of the uterus possesses a positive attrac¬ 
tion for them, as can be verified under the microscope. -That this view 
is correct is demonstrated by the instances of pregnancy following im¬ 
perfect coitus, and particularly those which have been observed in women 
with unruptured hymens. Furthermore, it has been shown by Henle 
that spermatozoa can move at quite a rapid rate, being able to travel 
a distance of 1 centimeter in three minutes. 


i 


l 




96 


MENSTRUATION AND OVULATION 


It was formerly taught that impregnation normally occurred in the 
uterine cavity, and it was believed by Tait, Wyder, and other observers 
that conjugation was favored by the direction of the currents produced 
by the cilia of the uterus and the tubes, the former being directed 
from below upward, and the latter from above downward, so that the 
two met in the upper part of the uterine cavity. Thus, the ciliary 
current would favor the entrance of spermatozoa into the uterus, while 
rendering impossible their entry into the tubes, except in diseased con¬ 
ditions. But in view of the observations of Hofmeier, Mandl, and 
others, which show that the ciliary current is directed from above down- ! 
ward, in the uterus as well as in the tubes, it is apparent that this 
theory must be abandoned, and it must be admitted that the spermatozoa 
have to make headway against the current from the time they enter the 
internal os. 

Years ago, Bischoff showed that large numbers of spermatozoa could 
be found upon the surface of the ovaries of animals within a few hours 
after copulation, and the occurrence of ovarian pregnancy demonstrates ; 
that the same may occur in women. From our knowledge of the sexual 
history of animals and women, it is universally admitted that sperma¬ 
tozoa promptly gain access to the tubes and that fertilization usually 
occurs at their lateral ends. Consequently, practically every pregnancy 
is primarily tubal, so that the question to be solved is how the fer¬ 
tilized egg gains access to the uterus. It is generally assumed that it 
is carried down by the ciliary current; but when it is realized how 
relatively large the egg is in comparison to the free space between 
the folds of the tubal mucosa, it may well be that muscular peristalsis 
also plays a part. In any event, the process is slow, being estimated by 
most authors at seven, and by Grosser at ten days. 

Until 1914, it was generally assumed that in married women, who 
copulate at ordinary intervals, living spermatozoa could always ut found 
in the tubes, into which they had made their way by their own motility. 
In other words, the tube might be regarded as a species of receptaculum 
seminis, in which living spermatozoa were always present and waiting 
for the ovum. 

The studies of TIoehne and Behne, however, disturbed this belief, 
as their experimental work indicated that spermatozoa live a much 
shorter time in the generative tract than was formerly believed, and 
perish after a stay of one and a quarter hours in the vagina, and two or 
three days in the uterus or tubes. If they are correct, coitus must occur 
within a few days of the time of ovulation if fertilization is to be 
effected, or else it must be assumed that unfertilized ova can live for 
days, which appears improbable. Nurnberger, on the other hand, be¬ 
lieves in the correctness of the older views, as he claims to have kept 
human spermatozoa alive in test tubes for seven or eight days, and was 
able to demonstrate motile spermatozoa in normal fallopian tubes, which 
had been removed thirteen or fourteen days after the last coitus. Such 
observations bear out the experience of Birch-Hirschfeld and Dtihrssen, 
and are in accord with the well known fact that in the bat spermatozoa 
retain their activity for months. In view of such conflicting opinions, 








LITERATURE 


97 


the question must be regarded as sub judice, until further work is avail¬ 
able. 

LITERATURE 

Aschiieim. Ueber den Glykogengehalt der Uterusschleimhaut. Zentralbl. f. Gyn., 
1915, 65-70. 

Aveling. Obst. Jour, of Great Britain and Ireland, July, 1874, 209. 

Beck. How Do the Spermatozoa Enter the Uterus? Amer. Jour. Obst., 1875, vii, 
353-391. 

Bell. Menstruation and Its Relation to Calcium Metabolism. Proc. Royal Soc. 
Med., July, 1908. 

Birch-Hirsch,feld. Quoted by Zweifel, Lehrbueh der Geburtshiilfe, II. Aufl., 
1889, 20. 

Bischoee. Die Entwickelung des Kaninchen-Eies. 1842. 

Christ. Das Verhalten der Uterusschleimhaut wahrend der Menstruation. D. I., 
Giessen, 1892. 

Coe. Internal Migration of the Ovum. Trans. Amer. Gyn. Soc., 1893, xviii, 
262-278. 

Corner. Cyclic Changes in the Ovaries and Uterus of the Sow, etc., 1921, Carnegie 
Inst. Publ. No. 276. 

Internal Migration of the Ovum. Bull. Johns Hopkins Hosp., 1921, xxxii, 78-83. 

Duhrssen. Lebendige Spermatozoen in der Tube. Zentralbl. f. Gyn., 1893, 593. 

Evans. The Rhythm of Gonadal Function with Special Reference to the Relations 
between Uterus and Ovary. Barker’s Endocrinology and Metabolism, 1922, 
II, 573-599. 

Findley. Anatomy of the Menstruating Uterus. Amer. Jour. Obst., 1902, xlv, 
509-512. 

Fraenkel. Die Function des Corpus luteum. Archiv f. Gyn., 1903, lxviii, 438- 
545. 

Neue Experimente z. Funktion d. Corpus luteum. Archiv f. Gyn., 1910, xcl, 
705-761. 

FrankiMi. Aschner. Zur quantitativen Bestimmung des tryptischen Fcrmentes 
in d. Uterusmucosa. Gyn. Rundschau, 1911, 647-654. 

Gebhard. Die Menstruation. Veit’s Handbuch der Gyn., 1898, iii, 1-94. 

Gendrin. Traite philosophique de medecine pratique. Paris, 1839. 

Gordon. Two Pregnancies Following the Removal of Both Tubes and Ovaries. 
Trans. Amer. Gyn. Soc., 1896, xxi, 104-108. 

Grosser. Ovulation und Implantation und die Funktion der Tube beim Menschen. 
Archiv f. Gyn., 1919, cx. 

Halban. Schwangerschaftsreactionen der foetalen Organen, etc. Zeitschr. f. Geb. 
u. Gyn., 1904, liii, 191-231. 

Halban u Kohler. Die Beziehungen zwischen Corpus luteum und Menstruation. 
Archiv f. Gyn., 1914, ciii, 575-589. 

Haller. Quoted by Ahlfeld, Lehrbueh, II. Aufl., 1898, 1. 

Henle. Lehrbueh der Anatomie. 

Hill and O’Donoghue. The Reproductive Cycle in the Marsupial Dasyurus Viver- 
rinus. Quart. Jour. Micros. Sci. N. S., 1914, lix, 133-174. 

His. Anatomie menschlicher Embryonen. 1880. 

Hitsciimann u. Adler. Der Bau d. Uterusschleimhaut. Monatschr. f. Geb. u. 
Gyn., 1908, xxvii, 1-81. 

Hoehne und Beiine. Ueber die Lebensdauer homologer und heterologer Sperma- 
tozoen im weiblichen Genitalapparat. Zentralbl. f. Gyn., 1914, o-20. 

Hofmeier. See literature on Anatomy of Uterus. 



08 


MENSTRUATION AND OVULATION 


Hoppe-Seiler. Ucber den Blutverlust bei dc.r Menstruation. Zeitschr. f. physiol. 
Chemie, xlii, 545. 

Jacobj. The Question of Rest for Women during Menstruation. Boyleston prize 
essay, New York, 1877. 

Jagerroos. Zur Kenntniss d. Veriinderungen d. Eileitersehleimhaut wahrend d. 

Menstruation. Zeitschr. f. Gcb. u. Gyn., 1912, lxxii, 28-4U. 

Jani. See literature on Anatomy of Uterus. 

Kahlden. Ueber das Verhalten der Uterusschleimhaut wahrend und nach der 
Menstruation. Hegar's Festschrift, Beitrage zur Geb. u. Gyn., Stuttgart, 


1889. 

Kehrer. Die Zusammenziehungen des weiblichen Genitalcanals. Beitrage zur 
vergleich. u. exp. Geburtskunde, Heft 1, 1864. 

Kelly. Operative Gynecology. 1898 ii, 189. 

Kennedy. Edinburgh Medical Journal, 1882, xxvii, 1085. 

Kristeller. Berliner klin. Wochenschr., 1871, Nr. 27, 28. 

Ivussmaul. Von dem Mangel, de.r Verktimmerung und Verdoppelung der Gebar- 
mutter und der Ueberwanderung des Eies. Wurzburg, 1859. 

Labille. De la quantite du sang que les femmes perdent au cours des regies. 

Annalcs de gyn. et d’obst., 1917, xii, 535-544. 

Leopold. Studien iiber die Uterusschleimhaut. Berlin, 1878. 

Die Ueberwanderung des Eies. Archiv f. Gyn., 1880, xvi, 22-44. 
Untersuchungen iiber Menstruation u. Ovulation. Archiv f. Gyn., 1885, xxi, 
347-408. 

Leopold und Mironoff. Beitrag zur Lehre von der Menstruation u. Ovulation. 
Archiv f. Gyn., 1894, xlv, 506-538. 

Leopold und Ravano. Neuer Beitrag z. Lehre von d. Menstruation und Ovula¬ 
tion. Archiv f. Gyn., 1907, Ixxxiii, 566-586. 

Lode. See literature on Anatomy of Uterus. 

Long and Evans. The Oestrous Cycle in the Rat. Berkeley, 1922. 

Lovcenhardt. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. 
Gyn., 1872, iii, 356-391. 

Lowenthal. Eine none Deutung des Menstruationsprocess. Archiv f. Gyn., 1884, 
xxiv, 169-261. 

Macht. A phyto-pharmacological study of a menotoxin or menstrual toxin. Proc. 

of The Soc. for Exp. Biology and Medicine, 1923, xx, 265-266. 

Marshall. Physiology of Reproduction. London, 1910. 

Marshall and Halnan. On the Postoestrous Changes Occurring in the Generative 
Organs of the Nonprognant Dog. Proc. Royal Soc. London, 1917, lxxxix, Ser. 
B, 546-659. 

Meredith. Pregnancy after the Removal of Both Ovaries for Dermoid Tumour. 
Brit. Med. J., 1904, i, 1360. 

Meyer. Ucber die Beziehung der Eizelle zum Follikelapparat, etc. Archiv f. 
Gyn., 1913, c, 1-19. 

Moericke. Die Uterusschleimhaut in verschiedenen Altersperioden und zur Zeit 
der Menstruation. Zeitschr. f. Geb. u. Gyn., 1882, vii, 84-137. 

Negrier. See literature on Anatomy of Ovaries. 

NIirnberger. Klin, und exp. Untersuchungen iiber die Lebensdauer der 
menschlichen Spermatozoen. Monatsschr. f. Geb. u. Gyn., 1920, liii, 87-101. 
Ott. Gesetz der Periodicitat der physiologischen Functionen im weiblichen Or- 
ganismus. Vehr. des X. internal, med. Congresses, Berlin, 1891, Bd. Ill, Abt. 
viii, 33. 

Pfluger. Ueber die Bedeutung u. Ursache der Menstruation. Berlin, 1865. 
Pinner. See literature on Anatomy of Uterus. 

Ploss. Das Weib in der Natur- und Volkerkunde, IV. AutL, 1895, Bd. I, 266-334 


LITERATURE 


99 


?ouciiet. See literature on Anatomy of Ovaries. 

Iouget. Recherches sur les organes erectiles de la femme. Jour, de la Physiologie 
1858, i, 320. 

Ruge. Ueber Ovulation, Corpus luteum u. Menstruation. Archiv f. Gyn., 1913 c 
20-48. 

Schick. Das Menstruationsgift. Wiener med. Wochenschr., 1920, Nr. 19. 

Schickele. Wirksame Substanzen im Uterus u. Ovarium. Miinchener med. 
Wochenschr., 1911, No. 3. 

Schroeder. Der liormale menstruelle Zykins der Uterussehleimhaut. Berlin, 1913. 

Ueber die zeitlichen Beziehungen d. Ovulation und Menstruation. Archiv f. Gyn., 
1914, ci, 1-35. 

Der Menstruationszyklus und seine Anomalien. Monatsschr. f. Geb. u. Gyn., 
1920, liii, 207-251. 

Siegel. Gewollte und ungewollte Scliwankungen der weiblichen Fruchtbarkeit. 
Berlin, 1917. 

Sigismund. Ideen iiber das Wesen der Menstruation. Berliner klin. Wochenschr., 
1871, 824, 825. 

Stickel u. Zondek. Das Menstrualblut. Zeitschr. f. Geb. u. Gyn., 1920, Ixxxiii, 
1-26. 

Stockard and Papanicolaou. The Vaginal Closure Membrane in the Guinea Pig, 
with Further Consideration of the Oestrus rhythm. Biol. Bulletin, 1919, xxxvii, 
222-245. 

Tait. See literature on Anatomy of Uterus. 

Thompson. Zur Frage der Tubenmenstruation. Zentralbl. f. Gyn., 1898, 1227. 

Van de Velde. Ovarialfunction. Wellenbewegung u. Menstrualfunction, Jena, 
1905. 

Webster. The Biological Basis of Menstruation. Montreal Med. Journal, April, 
1897. 

Wegelin. Der Glykogengehalt d. menschlichen Uterussehleimhaut. Centralb 1. f. 
allg. Path. u. path. Anat., 1911, xxii, 1-8. 

Wernich. Ueber die Erectionsfahigkeit des unteren Uterusabschnittes, etc. 
Beitrage zur Geb. u. Gvn., Berlin, 1872, 297-307. 

Williams. The Normal Structures of the Uterine Mucosa, and Its Periodical 
Changes. Obst. Journal of Great Britain and Ireland, 1875. 

Wyder. See literature on Anatomy of Ovaries. 









CHAPTER IV 


MATURATION, FERTILIZATION AND DEVELOPMENT OF THE OVUM; 

In the present work we shall not attempt to trace the development of 
the ovum through all its stages, but shall consider only those changes 
which are directly concerned in the formation of the foetal membranes 
and the placenta. For detailed information concerning the general 
development of the embryo the student is referred to the standard works 
upon embryology. 

Maturation of Ovum.—The ovum, as it occurs in the developing 
graafian follicle, is not adapted for fertilization and further development 
until it has undergone certain changes, more especially noticeable in its 
nucleus, which may be regarded as signs of maturation. This consists in 
the formation and extrusion of the polar bodies, which lead to the re- 



Fig. 88. 

Figs. 88-90.- 


Fig. 89. 


Fig. 90. 


-Formation of Polar Body (Sobotta). X 500. 

n., nucleus; V., vitelline membrane; F., yolk granules; P., polar spindle; S., head of 

spermatozoon. 


duction in the number of chromosomes to one half of that characteristic 
of the somatic cells. The process has not as yet been proved for the 
human ovum, but it has been demonstrated in human spermatocytes. 
Arthur Thompson in 1922 described and figured the formation and 
casting off of what he considered as polar bodies by ova still within 
the human o\aiy, but his conclusions have not obtained general accep¬ 
tance. On the other hand, Theophilus Painter and others have con¬ 
clusively demonstrated that a reducing division occurs in human 
spermatocytes, which results in the production of spermatids contain¬ 
ing only twenty-four instead of forty-eight chromosomes as in the 
spermatogonia and somatic cells. In view of these observations, as well 
a.'-' the fact that maturation of the ovum has been observed in all the 
the lower animals which have been studied, it must be assumed that it 
also occurs in man. The changes are supposed to begin just before the 

100 












MATURATION OF OVUM l01 

rupture of the follicle, and to be completed while the ovum is in the 
upper portion of the tube. The process is most readily understood by 
the study of ova having but few large chromosomes. Accordingly, the 
egg of the ascaris megalocephala, which possesses four chromosomes, is 
well adapted for its demonstration. 

Sobotta has made an exhaustive study of the process in the mouse, 
and it is from his article that most of our statements are taken. When 


Fig. 91. —Diagram shov/ing Normal Cell Fig. 92. —Diagram showing the Reduc- 
Division with Four Chromosomes. tion in the Number of Chromosomes 

a, cell with four chromosomes; b, forma- IN THE Maturation of the Ovum. 
tion of spindle; c, splitting of chromo- a-b-c, oocyte of first order in various 
somes in spindle; d, separation of daugh- stages of division; d, oocyte of second 
ter chromosomes; e, complete separa- order; e, first polar body; /, mature 

tion into two cells, each with four chromo- ovum; g, second polar body; h, cells 

somes. derived from division of first polar body. 

the process of maturation is about to begin, the germinal vesicle ap¬ 
proaches the surface of the ovum, or oocyte of the first order, and appears 
to become smaller, while at the same time its membrane disappears. 
It gradually becomes less and less distinct, until finally its situation 
is indicated by a clear area surrounded by deutoplasm, which is traversed 
by many radiating lines. In a short time this becomes transformed 
into a typical caryocinetic or mitotic figure, which undergoes the usual 
changes and soon becomes spindle-shaped. The spindle, when it first 






102 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


appears, is situated tangentially to the surface of the ovum, but later 
turns and becomes perpendicular to it. The chromatin of the spindle 
then becomes rearranged and a typical dyaster is formed (Figs. 88-90). 
Division rapidly ensues, and the new nucleus nearest the surface, with 
the portion of protoplasm surrounding it, is cut off from the bulk of 
the ovum and comes to lie between it and the vitelline membrane. In 
this way is formed the first polar body and the oocyte of the second order. 
As the process is a typical cell division, the nucleus of both the polar 
body and of the oocyte will contain the typical number of chromosomes. 

Almost immediately a new spindle appears in the oocyte, and division 
occurs without preliminary cleavage of the chromosomes, so that two 
cells are formed, each of which has onlv one half the number of chro- 
mosomes characteristic of the species. The smaller of these is cast off 
as the second polar body, while the remaining large cell is the mature 
ovum, whose nucleus is then designated as the female pronucleus. 

As the first polar body is formed by typical cell division, it must be 
regarded as homologous with the oocyte, from which it differs only by 
its smaller size; and it may divide again, giving rise to two cells. On 
the other hand, the second polar body is homologous with the mature 
ovum, and contains only one half the number of chromosomes char¬ 
acteristic of the body cells. Under abnormal conditions it may likewise 
become fertilized; in which event, according to the theories of Bonnet, 
Wilms, and Marc-hand, it may play a part in the production of a 
teratoma. It would therefore appear that in the process of maturation 
six cells may develop from the original oocyte of the first order: by 
the nonreducing division, the oocyte of the second order and the first 
polar body ; while by the reducing division the oocyte gives rise to the 
mature ovum and the second polar body, and the first polar body to 
two cells homologous with the second polar body (Fig. 92). 

Maturation is essentially a means 
of reducing the number of chrom¬ 
osomes, though its exact significance 
is not clear. Following the theory of 
Weissman, it is generally believed that 
the object of the reduction is to make 
possible the introduction of paternal 
chromosomes into the ovum at the 
time of fertilization, without increas¬ 
ing the number of chromosomes char¬ 
acteristic of the species, as must in¬ 
evitably occur were some such mechan¬ 
ism not provided. In any event, the 
process must be regarded as a neces¬ 
sary preliminary to normal fertiliza¬ 
tion and further development of flu* 
ovum. 

As the researches of von Winiwarter and Painter show that in human 
beings the somatic cells, as well as the spermatogonia and spermatocytes 
o( the first order, contain forty-eight chromosomes, it must follow that 



Fig. 93.—Human Spermatogonial 
Division, with 48 Chromosomes. 
(Painter). 






FERTILIZATION 


103 


the number is reduced to twenty-four in the spermatozoon, and inferen- 
tially in the mature ovum and second polar body. 

Fertilization.—By fertilization is understood the union of a sperma¬ 
tozoon and a mature ovum. Each spermatozoon must be regarded as a 
distinct cell, and consists of three portions—the head, 
which contains the nuclear material, the tail, and an 
intermediate portion. The head is somewhat tri¬ 
angular in shape and flattened from side to side. 

Interpolated between it and the long tail is a small 
cylindrical body, the intermediate portion (Fig. 94). 

The spermatozoa are endowed with marked motility, 
derived from the rapid vibration of their tails, and, 
according to Henle, can traverse a distance of 1 cen¬ 
timeter in three minutes. 

In spermatogenesis, changes are observed analo¬ 
gous to those occurring in the maturation of the 
ovum, and it has been clearly shown that each 
spermatocyte of the first order divides into two cells, 
each of which in turn gives rise to two others con¬ 
taining onlv one-half the number of chromosomes 
characteristic of the species (Fig. 95). These latter 
are the spermatids, which later become the sperma¬ 
tozoa. Each spermatozoon, therefore, must be re¬ 
garded as analogous with the mature ovum and the second polar body. 
Fig. 93, from Painters monograph, shows that the human spermatocyte 
contains forty-eight chromosomes, consequently each spermatozoon must 
contain twenty-four. 

As has already been pointed out, the spermatozoon and ovum usually 
come together in the lateral portion of the tube, although in rare in¬ 
stances the meeting may take place on the surface of the ovary or even 
in the graafian follicle, as is demonstrated by the occurrence of ovarian 
pregnancy. 

In the lower animals in which the process of fertilization has been 
studied, the ovum is found in the lateral end of the tube, surrounded 
by a considerable number of spermatozoa, as many as 60 having been 
counted about a single ovum. These rapidly penetrate the vitelline mem¬ 
brane, but it appears that normally only one of them makes its way 
into the ovum, and that after its entry the superficial portion of the 
latter becomes impervious to other spermatozoa. 

After the head has entered the ovum the tail rapidly disappears, and 
in a short time nothing is left of the original spermatozoon but a 
small spindle-shaped mass, the male pronucleus (Fig. 90). This rap¬ 
idly makes its way to the center of the ovum, where it meets and fuses 
with the female pronucleus to form the segmentation nucleus. 

As the male and female pronuclei each contain one half the number 
of chromosomes characteristic of the species, their union restores the 
normal number (Fig. 96). Thus, in ascaris, two of the chromosomes 
of the segmentation nucleus are of paternal and two of maternal origin, 
while in man twenty-four come from each cell. Moreover, as the 



Fig. 94. — Human 
Spermatozoa. 

h, head; c, interme¬ 
diate portion; f, tail. 




104 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 

chromosomes of both the mature ovum and the spermatozoon are the j 
direct descendants of those concerned in the fertilization of the parent 
organisms, it is apparent that the process does not consists merely in 
the union of so many paternal and maternal chromosomes, but has a 
much broader significance, in that it brings together nuclear substances 
derived from the ancestors of both parents, and thus affords a basis 




Fig. 95—Diagram showing the Reduc¬ 
tion in the Number of Chromosomes 
in Spermatogenesis in a Species with 
Four Chromosomes in Somatic Cells. 
a-b-c-, spermatocyte of first order in 
various stages of division; d, sperma¬ 
tocytes of second order; e, spermatids 
with two chromosomes each. 




Fig. 96.—Diagram showing Fertiliza¬ 
tion and Segmentation of the Ovum. 

a, fertilization; 1, male pronucleus; 2, 
female pronucleus; b-c, formation of 
spindle with chromosomes derived from 
both ovum and spermatozoon; d-e, cell 
division showing perpetuation of pa¬ 
ternal and maternal chromosomes in body 
cells. 


for a comprehensible theory of heredity. Consequently, in the case of 
man, in which the fertilized ovum contains forty-eight chromosomes, 
it is apparent that an almost endless number of combinations are possible. 

Ordinarily segmentation does not begin until after fertilization, but 
it is well known that in many insects it is not dependent upon the 
fusion of the male and female elements, as normal individuals may 
develop from unfertilized ova—parthenogenesis. Moreover, it has been 







GENERAL DEVELOPMENT OF OVUM 


105 


»repeatedly shown that segmentation may be inaugurated in various 
animals without the presence of spermatozoa by subjecting the mature 

I ovum to the action ol various chemical agents, such as weak solutions 
of acids or alkalis—artificial parthenogenesis. In such cases develop¬ 
ment appears to progress normally up to a certain point, but at present 
there is no evidence available to indicate that thoroughly formed animals 
will result. 

It is now generally admitted that in such circumstances the egg 
casts off two polar bodies, as usual, so that the cells resulting from 
its segmentation will possess only one half as many chromosomes as 
when fertilization occurs. Accordingly, it would appear that the process 
of fertilization may be resolved into two parts: the fusion of the male 
and female chromosomes, and the inauguration of segmentation. In the 
higher animals it would seem that the two functions are inseparable, 
while experiments upon artificial parthenogenesis in some of the lower 
species indicate that the latter may occur independently of the former. 
In view of such facts, Loeb in 1909 stated that the spermatozoon may 
be regarded as an activator, which serves to stimulate nuclein synthesis. 
For a time it was believed that the centrosome—the structure which 



Figs. 97-99.— Changes in the Segmentation Nucleus (Sobotta). X 500. 

P., polar body; s.n., segmentation nucleus. 


apparently presides over the act of cell division—disappeared from the 
ovum during the last phases of maturation, and accordingly the mature 
ova could not begin to segment until the lacking structure had been 
restored by means of the male pronucleus. This, however, cannot be 
accepted as a universal rule, particularly in view of the fact that such 
a possibility is lacking in artificial parthenogenesis. 

General Development of Ovum.—Soon after the appearance of the 
segmentation nucleus, caryocinetic changes take place within it and ghe 
rise to a typical nuclear spindle, which is soon converted into a dyaster, 
to be speedily followed by the division of the ovum into two cells (Figs. 
97 to 99). Each of these in turn divides, giving rise to four cells, 
though Sobotta’s investigations on the mouse show that one of the 
original cells divides earlier than the other, so that we next ha\e tlnee 
cells. This process of cell division or segmentation goes on until the 
original ovum becomes converted into a mass of cells, which is desig¬ 
nated as the morula, or mulberry mass (Fig. 102). 









106 


MATURATION, 


FERTILIZATION AND DEVELOPMENT OF OVUM 


Fluid soon appears in the interior of the mulberry mass and forces 
the cells to the periphery, thus giving rise to a vesicular structure con¬ 
sisting of a single layer of cells which surround a cavity filled v ith 
fluid—the segmentation cavity. The entire structure at this time is 
known as the blastodermic vesicle, which in the rabbit and many other 



Fig. 100. Fig. 101. Fig. 102. 

Figs. 100-102.— Formation of Mulberry Mass (Sobotta). X500. 



animals is still surrounded by the vitelline membrane (Fig. 103), whereas 
in the mouse the latter disappears before the formation of the mulberry 
mass. 

In a short time a collection of several layers of cells can be noted 

at one point on the inner 
surface of the blastodermic 
vesicle. This is know r n as 
the internal cell mass, while 
the single layer of cells 
forming the wall of the 
vesicle is frequently spoken 
of as the primitive chorion 
(Fig. 103). When viewed 
by transmitted light the in¬ 
ternal cell mass appears 
darker than the rest of the 
surface of the blastodermic 
vesicle, and hence is called 
the macula embryonalis. 
Sections made through it at 
this point show that it is 
composed of several layers 
of cells, those nearest the 
exterior being ectodermal, 

and those nearest the segmentation cavity entodermal in character. 

The formation of a blastodermic vesicle has not as yet been observed 
in the human ovum, but, as it has been demonstrated in the ova of all 
species of animals which have been available for study, there is no doubt 
that it occurs in all mammals. These changes are supposed to take 
place while the ovum is making its way through the tubes, or just after 
it has become implanted upon the uterine mucosa. Since the studies 
of Graf Spee show that in the guinea pig the blastodermic vesicle is not 


Fig. 103.— Blastodermic Vesicle of Rabbit 

(v. Beneden). 

c., cavity of vesicle; ect., primitive ectoderm; i.c.m .. 
internal cell mass; z.p., zona pellucida; e., al¬ 
buminous envelope. 


I 






















GENERAL DEVELOPMENT OF OVUM 


107 


formed until after the ovum lias become imbedded in the decidua, it 
is probable that the same holds good for man. The transit through 
the fallopian tube is believed to occupy a period of from five to seven 
days, as has been verified in the guinea pig, and appears probable in 
human beings. 



tissgi 


,0 •M***J*«V’»*2*i' 53v?*»sSi» 


Following the formation of the blastodermic vesicle and its internal 
cell mass, the further development of the ovum varies according to 
the intimacy of its attachment to the uterine wall. If it merely adheres 
to the surface of the decidua, as in the rabbit and dog, and there is 
an abundance of space in the uterine cavity, important changes con¬ 
nected with the development of the embryo and its enveloping mem¬ 
branes promptly occur upon the surface of the vesicle. On the other 
hand, if the ovum is very minute and buries itself in the depths of the 
uterine mucosa, these changes are lacking, and further development 
takes place in the interior of the vesicle—the so-called “inversion” 
of the germ layers, to which attention was particularly directed by 
Selenka in 1884. At first this was considered peculiar to certain rodents, 
but it is now known to occur in many other mammals, and in all 
probability in man. We shall accordingly briefly consider the changes 
occurring in the 
rabbit and dog, 
and then take up 
in more detail 
those observed in 
man. 

In the first 
mentioned ani¬ 
mals, the cells 
composing the in¬ 
ternal cell mass 
proliferate, a n d 
soon give rise to 
a round or oval 
area at one point 
on the surface of 
the blastodermic 
vesicle—the em¬ 
bryonic area , 
which at first 
consists of two 
layers of cells 
representing the 

ectoderm and en¬ 
toderm respectively. The embryonic area, when viewed by trans¬ 
mitted light, is first round, but later oval in shape, and presents a 
dark center and a light periphery, which are designated respectively as 
the area opaca and the area pellucida (Fig. 104). This differentiation 
is due to the fact that the cells composing the former are arranged m 
several layers, whereas in the latter only two can be made out. 


• # • • 


• o© 








♦ • • • * 




M.S. 


Fig. 104.— Embryonic Area, Dog (Bonnet). X 90. 
A.C., area opaca; A.P.. area pellucida; M.S., mesodermic 
sickel; P.S., primitive streak. 






108 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVITM 




The embryonic area soon becomes slightly elevated above the general 
surface of the blastodermic vesicle, and now forms what is known as the 
embryonic shield. A few hours later a darker zone appears at one end | 
of the shield and soon exceeds it in size (big. 104, M.S.). This is the 
mesodermic area , which on section is seen to be made up of spindle- 



Fig. 105. —Section through Early Embryonic Area of Dog (Bonnet). X ISO. 

Ec., ectoderm; Ent., entoderm. 



Fig. 106.—Embryonic Shield of Rabbit, 
showing Primitive Streak and Med¬ 
ullary Folds (Kollmann). X 28. 


Fig. 107.— Chicken Embryo with Five 
Segments (Kollmann). 

H.f., head fold; M.f , medullary folds; P. t 
primitive streak; P.s., primitive seg¬ 
ments; P.z., parietal zone; S.z., seg¬ 
mental zone. 


shaped and triangular cells. This area rapidly increases in size, and 
soon forms a complete layer inside the blastodermic vesicle between the 
ectoderm and entoderm. 

A little later there appears in the middle of the embryonic area a 
(slight depression—the primitive streak —which is bounded on either 
side by a slight elevation—the primitive folds (Fig. 104, P.S.). Shortly 
afterward a second depression—the medullary groove —appears in front 


















































GENERAL DEVELOPMENT OF OVUM 


109 


of the primitive streal:. It is bounded on either side by an elevated 
fold—the medullary ridges—which converge anteriorly to form the head- 
folds. The medullary groove is in the same line with the primitive 





P3 


Fig. 108.— Section through Embyronic Area of Dog showing Three Layers. 

(Bonnet). X 180. 

Ed., ectoderm; Ent., entoderm; M., mesoderm; M.G., medullary groove. 

streak, but never unites with it; while the medullary folds diverge 
posteriorly and inclose the anterior end of the primitive streak (Fig. 
106). As the ovum becomes older the medullary groove and folds, 
which result from proliferation of the ectoderm and later give rise to 


• * 

__ ^ . v • . ^ 1 . • 








•A 


%ag«r 


&<* A'?' 

OBi_ 


•• • - • ifc ‘ 


(f 

.. JA 

% ■ ' ■&&& 

- m ■ jg Ent. 


Fig. 109.— Section through Dog Embryo showing Greater Development of Meso- 

dern (Bonnet). X 180. 

Ed., ectoderm; Ent., entoderm; M., mesoderm; M.G., medullary groove. 


the central nervous system, rapidly increase in size; while the primi¬ 
tive streak remains stationary, so that in a short time it occupies only 
an insignificant portion of the embryonic area. 

While these changes are taking place on the surface of the embryonic 





AM0OJS.fc.5W 


Fig. 


C 




110.— Section through Dog Embryo showing Formation of Annion (Bonnet). 

X 100. 

celom; Ch., notochord; Ed., ectoderm; Ent., entoderm; M., mesoderm; Som., 

somatopleure; Spl., splanchnopleure. 


area, others of no less importance are going on in its depths, which 
result in the formation of the mesodermic structures. On either side 
of the medullary canal can be observed a slight thickening—the seg¬ 
mental layer, outside of which is a thinner layer the parietal zone 





110 


MATURATION, FERTILIZATION 


AND DEVELOPMENT OF OVUM 


(Fig. 107). The segmental layer soon becomes divided up into a num¬ 
ber of more or less cuboidal masses of tissue on either side of the 
medullary groove, which are variously designated as pi otovei I< biae, 
primary segments, or mesoblastic somites \ from these the musculature 


Fig. 111. —Section through Dog Embryo showing Formation of Amnion, with 
Greater Development of Somatopleure (Bonnet). X 100. 

C., coelome; Ch., notochord; Ed., ectoderm; Ent., entoderm; M., mesoderm; Som., 

somatopleure; Spl., splanchnopleure. 



of the dorsal portion of the body is developed. The parietal zone, 
which is also made up of mesoderm, soon becomes divided into two 
layers which inclose a cavity, the celom. The outer layer is covered by 
ectoderm, and is designated as the somatopleure, while the inner is 
lined by entoderm and is called the splanchnopleure. From a part of 



Fig. 112.—Diagram representing Longitudinal Section through Mammalian 

Embryo, showing Formation of Amnion. 

the former the anterior and lateral abdominal walls are developed, 
while in many animals its greater portion gives rise to the chorion and 
amnion. 

Thus far we have considered the growing ovum as seen from without; 






IMPLANTATION OF THE HUMAN OVUM 


111 


but the study of microscopical sections through it aids us still further 
in understanding its development. Fig. 105 represents a section through 
the embryonic area at an early period, and shows that the greater part 
of the blastodermic vesicle is composed of two layers of cells, the ecto¬ 
derm and the entoderm, while in the region of the embryonic area the 
former is arranged in several layers, whereas the latter consists of a single 
layer. Fig. 109 represents a section through the embryonic area of a 
dog at a little later stage, and shows three distinct layers—ectoderm, 
mesoderm, and entoderm. In Fig. 110 a still later period of develop¬ 
ment is shown; the medullary groove is well marked, and the mesoderm 
has become thickened to form the segmental layer, lateral to which 
is the parietal zone, which has already split, giving rise to the meso- 
dermic layer of the somatopleure and splanchnopleure. 

From the ectoderm are developed the central nervous system and the 

cutaneous structures; from the mesoderm are derived the muscular 

and circulatory portions of the body, the reproductive organs and the 

connective-tissue framework of the various other organs; while the 

entoderm gives rise to the digestive tract and the organs which are more 

or less intimatelv connected with it. 

*/ 

In the chicken, rabbit, dog, and many other mammals the chorion 

and amnion are not formed until 
the embryo has assumed definite 




Fig. 113. —Guinea-pig’s Ovum Attached 
to Uterine Mucosa, Seventh Day 
(Spee). X 375. 

C., segmentation cavity; Ep., uterine epi¬ 
thelium; O., ovum; Z., zona pellucida. 


Fig. 114. —Ovum of Guinea-pig Bur¬ 
rowing through Uterine Mucosa, 
Seventh Day (Spee). X 375. 

C., capillary; D., decidua; Ep., uterine epi¬ 
thelium; O., ovum. 


proportions, and the parietal layer of the mesoderm has become well 
developed and, together with the ectoderm and entoderm, has been 
differentiated into the somatopleure and splanchnopleure (Figs. 110 
and in). Then folds of somatopleure arise at the head and tail ends 
and sides of the embryo and, gradually arching over it, meet together 
and fuse, thus inclosing its dorsal surface within two membranes. The 
outer of these, the chorion, is composed of an outer layer of ectoderm 
and an inner layer of mesoderm; while in the inner membrane, or 
amnion, the mesoderm is without and the ectoderm within, toward the 
embryo (Fig. 112). 

Implantation of the Human Ovum. —As has already been indicated, 
the human ovum has not as yet been observed during the process of 



112 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 

segmentation nor in the earliest stages of implantation. Arguing 1)) 
analogy. Grosser supposes that it reaches the uterine cavity and be¬ 
comes implanted upon it lining membrane seven days after fertilization. 
At that time it is probably still in the morula stage and, as the cells 
composing it have become progressively smaller with each division, it 
is assumed that it scarcely exceeds the mature ovum in size—namely, 
0.2 millimeter or 1/125 inch in diameter (Figs. 1 to 3, Plate IV A). 

These, however, are mere suppositions, but, as the youngest ova 
with which we are acquainted are already deeply imbedded in the decidua, 
we are forced by analogy to believe that implantation is effected in 



n.z. pi. 


cap pi' 


*«’ 


pi. n.z. 


Fig. 115.—Diagram of Teacher-Bryce Ovum. X 50. (T. H. Bryce, Del.) 

P.e., point of entrance; cyt., cyto-trophoblast; pi., plasmodi-trophoblast; n.z., necrotic 
zone of decidua; gl., gland; cap., capillary; pi., masses of vacuolated plasmodium 
invading capillaries. The cavity of the blastocyst is completely filled with meso- 
blast, and imbedded therein are two cavities, the larger one representing the amnio- 
embryonic vesicle, and the smalLer one the yolk sac. 


somewhat the same manner as in the guinea pig. Graf Spee has demon¬ 
strated that the ovum of that animal reaches the uterus during the 
seventh day after fertilization while still in the morula stage, when, 
owing to the viscidity of its exterior, it becomes attached to the free 
surface of the endometrium. As a result of a supposed digestive action, 
the epithelium directly beneath it is destroyed and the stroma liquefied, 
so that the ovum gradually sinks into the decidua and comes to lie 
well beneath its surface. Following this the margins of the opening 
coalesce, so that the ovum is eventually buried in the depths of the 
decidua, and has no communication with the uterine cavity (Figs. 
113 to 115 and Figs. 4, 5 and 6, Plate IV A). 














PLATE 


)& 


|G. 


.Cap 


Mes. 


tef. 


s y 




• • • 

• • * 

„ :»7- 

• • <> .' ••V . 1 •*-“ oJ5R 

• 0 • 




-it 






: i*.' 




- • ,v • 


11. s. 


Sy 








*\ . ; 






•■» • * >>' 




; :.rS ? ?fc & 

* vO". # • 0 * / 


•,0 V? 


ap. 




.»..» 


x §°o \.;? • ? , 

“ iv & 

*:•<* eiCJ’gsfci /••• 

o* %:•:•.? V %. *• : .+y:/l, 
-..Ww oo* ... ./ITT 

.... ... • ®(J|. 4 v.-s; y O • ^ / jy 

/ § 7v v ■ ° o* ■ y.iv/yi 


,vV;.V ••* 




K? 


0 * 

v ® , V* s • , 

/v .7 • «if« r %K* .4 y 

iJ-i' a ' < . * T •• '• :: 

• ,• V^.O 4 5.1 -V 

•»*' x® * 1 i *»* '}*• y l\ •• * •■<•*• 

> ';’• i ,> . •' - o /.• V' - V•' 




■* . 9 :• V 

■ i . °< j . 




:v#fe£- 






• . *•-. 


BIS. 


>>V V 
f w • 


Erab. / 




’t ' * •* \"»'T * • 

• r f - h'ile'P' 

i» ». 1 ^ i / ' «•<» , * 

:.... . j . .V * * ' . V:V;r*f 

1>N a- 7 • > # «'# ••• • * 

7. 7 s » * . ** . 

>. y. •' 

“ / < v •; 4 „• - . 

/ ♦;»>• , * / • /-it• *, e 

^4 •• V;-, - / ' v > •' f• G. 

'x-^a V A: ^ 






' cl 


v — i 1 

• ' f• < 


>■/> •. . • 


I.'s: 

.*; *• */ • 


■. •■• s 
\ • 0 




d oOO q -° 




8 -OOP' 

yoooo 00 -" 




Mes. 


G. 


D.C. 


Cap. 


Comp. 


PETERS’S OVUM. X 50. 

Bl.S., blood spaces; Cap., capillary; Comp., compact layer of decidua; D. C., decidual cells; 
Emb., beginning embryo; Fib., mass of fibrin covering point of entry of ovum into 
decidua; Mes., connective-tissue layer of chorion; lie/., decidua reflexa; Syn., syn¬ 
cytium; 77., trophoblast; U. E., uterine epithelium. 































































































IMPLANTATION OF THE HUMAN OVUM 


113 


Such a procedure does not imply so radical a destruction of tissue 
as one might suppose, and Spee states that it involves an area only 
the width of a few epithelial cells. Moreover, the digestive action is 
not entirely hypothetical, as Grafenburg has demonstrated that human 
foetal ectoderm contains a tryptic ferment, which is capable of digesting 
culture media in laboratory experiments. 

3, ^ e \ e d t It a t in women the ovum was implanted 

upon the free surface of the endometrium, which had become transformed 
into a decidua for its reception, and eventually became cut off from the 
uterine cavity by an encapsulating upgrowth of the adjacent tissue— 
the decidua capsularis; but, as early as 1896, Herff stated that it prob¬ 
ably become implanted by a mechanism similar to that observed in the 
guinea pig. Such views, however, were not seriously considered until 
three years later (1899), when Peters described a very early ovum in 
situ (Plates I\ and I\ B). As this was deeply imbedded in the decidua 
and was completely separated from the uterine cavity, it became apparent 
that the views previously held concerning implantation were erroneous, 
and Peters concluded that it could be explained only by some such 
mechanism as that described by Spee. Since that time a constantly in¬ 
creasing mass of evidence has accumulated in support of such a view, 
which is now universally accepted as correct. 

Up to the beginning of 1923 at least fifteen early ova in situ have 
been described, none of which exceed 5 millimeters in diameter, and 
which vary from the latter part of the second to the end of the third 
week in age. They were described by the following authors, and are 
mentioned as far as possible in order of their age: Miller, Bryce and 
Teacher, Linzenmeier, Peters, Fetzer, Moellendorf, Kiss, Schlangen- 
haufer and Yerocay, Heine and Hofbauer, Leopold, Herzog, Jung, 
Merttens, Strahl-Beneke, and Spee. Several other early human ova 
have also been described, as well as many at a somewhat more advanced 
stage of development, which permit conclusions as to the mechanism of 
implantation; more particularly a second ovum described by Moellen¬ 
dorf, which is not included in the preceding list for the reason that 
it is distinctly abnormal. In each instance the ovum was imbedded in 
the superficial portion of the decidua and was separated from the 
uterine cavity by a definite, but thin, layer of tissue, and, when the 
entire uterus was available for study, appeared as a minute vesicular 
structure whose upper pole projected somewhat above the general surface. 
In not a few instances, a funnel-shaped defect apparently marked the 
point of ingress of the ovum, while in a certain number of specimens a 
mushroom-shaped mass of fibrin infiltrated with leukocytes covered it. 

The youngest of these ova was described by Miller in 1913 and 
was probably ten or eleven days old; that of Bryce and Teacher was 
probably thirteen days old; no data are available for calculating the age 
of Linzenmeier’s ovum, but it is clearly younger than that of Peters, 
which is estimated to be 17 or 18 days old. The remainder of the ova 
in the series are about the age of Peters’ ovum, but none are older than 
the end of the third week after fertilization. 

As has already been intimated, no direct evidence is available as 


114 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 

to what happens to the ovum between the time of fertilization and the 
stage represented by Miller’s specimen, ten or eleven days later. This 
ovum was deeply imbedded in the decidua, measured 0.83 millimeter 
in its greatest diameter and was in a relatively advanced stage of de¬ 
velopment. If we admit with Grosser that a period of at least seven 
days elapses between fertilization and implantation, it may be assumed 
that this ovum represents the extent of development which occurs during 
the three or four days immediately following implantation, and that 
what is needed is information concerning the intermediate stages. 

In order to supply this temporary deficiency, Mr. Broedel was kind 
enough to prepare Plates IV, A and B, in which Fig. 1 represents the 
mature ovum pictured in Fig. T9, while Figs. 7-10 represent the ova of 
Miller, Linzenmeier, Bryce and Teacher, and Peters, respectively, each 
magnified 50 diameters. Figures 2 and 3 represent the ovum in the two¬ 
cell and morula stage, and Figs. 4-6 represent hypothetical ova in various 
stages of implantation preceding that observed by Miller. These latter 
figures are slightly modified from those prepared by Graf Spee, and 
may or may not correctly represent what actually occurs. However that 
may be, the plate gives a graphic idea of the phenomenal changes which 
occur in the 17 or 18 days elapsing between fertilization and the stage 
of development represented by Peters’ ovum, and shows beyond per- 
adventure that the human ovum early makes its way into the depths of 
the decidua, and does not remain upon its surface as was formerly sup¬ 
posed. 

Formation of the Chorion and Amnion.—In each of the early ova 

depicted in Plates IV, A and B, it is seen that the center of the ovum con¬ 
sists of very loosely meshed mesodermic tissue, containing as its basal 
portion a small mass of cells, as in Miller’s specimen, or two minute 
cavities, as in Figs. 8, 9 and 10, to which reference will soon be made. 
Outside of this comes a capsule of ectodermal tissue—the trophoblast, in 
which two types of cells can be distinguished. The first, immediately 
adjoining the mesodermic tissue, consists of a single layer of cells with 
sharply marked outlines; while the second, which also contains indi¬ 
vidual cells, is characterized by the presence of masses and hands of 
protoplasm containing nuclei, but not divided into individual cells. 
The trophoblastic capsule, which is the most characteristic feature of 
the ovum at this time, varies greatly in thickness in its several portions, 
is actively invading the surrounding maternal tissue and opening up its 
blood vessels and gland spaces. 

In Peters’ ovum the mesodermic tissue has in great part become 
consolidated into a thin layer immediately inside of the trophoblast, 
while from its periphery outgrowths extend into the latter and repre¬ 
sent the earliest stage in the formation of chorionic villi. At this period 
the trophoblast with its mesodermic lining constitutes the chorion, while 
the cavity included within it is designated as the extra-embryonic coelom 
or magma cavity. 

In Miller’s ovum the small collection of cells at the basal portion 
of the mesodermic core represents the embryonic mass, while in the ova 
of Linzenmeier and Peters two cavities surrounded by mesoderm are 



PLATE IV, A 



Vitelline membrane 


'Vitelline memb. 
LGerminal vesicle 
■Germinal spot 


Blastomeres 


( Morula] 


16 cell stage 


0.2 mm 


Zona peUucida 


Tvopboblsst 
*gfek, Embryo 


Tropho blast 
-Embry- 


'omc mass 
Uterine epith 


.Blastodermic cavity 


Uterine epithelium 
Decidua 


zv» V-vr 






’S* 

V.» 'Xt.* 


ro ph oblast 
Ectoderm 


7 '^ YO h ^ b l a »t 


Entoderm 

?Vu Uterine epith 


li&W* 

&M f 


Coelom 




m 


*«»**•" i - 


»•.>%£ 


min 


Exocoelomic mesoderm 


prop hob last 


Flxocoelomic mesoderm 




<•» 


Uterine epithelium 


Trophoblast 


LV^j X5, 


Litnzenmeier 

t.05 x 0.9 mm 


Uterine gi-and 


x 50 


DIAGRAM ILLUSTRATING CHANGES IN THE FERTILIZED 









PLATE IV, B 







of entrance 


Jterine epith. 


fiV- 


Ri 

■<f w ' %>_ ■ 

♦5v\ 


^lasmodi- 
Ycph oblast 


Syto - 

frophoblast 

'.'v 

\u 

-., V 


Entoderm 
Mesoderm 

Ectoderm 


Capillary 


« s ,^i.5 Gland 


' 9 

Bryce -Teacher 
1.95 x 0.95 mm 



Uterine epithelium 


* vT , '- ,k * •* s * 

yv*’ :vr;y- 

-«r, , *>***>■* * VMW?'♦.«* 




SCJn- - • > . 


f • 

k;^ 


Mesoderm 


*Yol Ksac 


•*V* 




Peters 

x 1.8 m m 


mruon 


OVUM DURING THE PROCESS OF IMBEDDING 
































FORMATION OF THE CHORION AND AMNION 


115 


present, and represent the amnion and the yolk sac. In the lining of 
the former, two types of cells may be distinguished—first, a single layer 
of flattened cells, which constitute the amniotic epithelium and second, 
several layers of large ectodermal cells, which constitute the embryonic 
plate or shield, which, however, at this time shows no sign of further 
differentiation. The yolk sac is surrounded by mesodermal tissue and 
is lined by a single layer of entodermal cells. 

In other words, these early ova already present the three primary 
germ layers—ectoderm, mesoderm and entoderm, and consist of a rela¬ 
tively highly developed chorion with its mesodermic and trophoblastic 
layers inclosing a large ccelomic cavity, and a relatively small flattened 
amniotic cavity, one side of which is occupied by the embryonic shield, 
which as yet presents no sign of the future embryo. It is, therefore, 
apparent that in man the chorion and amnion do not develop in the 
same manner as in the chick, rabbit or dog, as in them there is no sign 
of the amnion until the- embryo has taken on a distinct form, when it 
appears as folds of somatopleure which arch over the embryo and even¬ 
tually meet and fuse. Furthermore, the mesodermic tissue has attained 
a degree of development far out of proportion to that observed in those 
animals. 

Consequently, some other mechanism must be invoked to explain 
their formation in man. In many mammals, particularly when abundant 
room is not available in the uterine cavity for the expansion of the 
foetal membranes, the embryonic mass develops upon the interior, in¬ 
stead of upon the exterior, of the blastodermic vesicle, giving rise to the 
so-called inversion of the membranes—“entypie.” This process has been 
studied particularly by Spee and Duval in the guinea pig, by Sobotta in 
the mouse, and by Huber in the white rat, but probably does not occur 
in man, for the reason that in the animals mentioned only a small 
portion of the periphery of the ovum is composed of chorion, while its 
greater part is covered by entoderm homologous with that lining the 
yolk sac; whereas in man the chorion persists up to the time of birth 
as the outermost membrane of the product of conception, and the yolk 
sac is preserved as a closed vesicle until the termination of pregnancy. 

All authorities agree in assuming 
that following fertilization the hu¬ 
man ovum undergoes segmentation 
and eventually becomes converted 
into a blastodermic vesicle, but here 
the analogy with what occurs in the 
chick, rabbit, or dog ceases; and the 
evidence available indicates that in 
man the embryonic mass or area 
develops upon the interior of the . 

blastodermic vesicle, rather than upon its exterior, as in the animals m 
question. At the same time, the process differs materially from “entypie” 
as it occurs in many rodents. For these reasons, it appeals conceivable 
that the changes which occur in the human ovum during the first few 
hours or days following implantation may resemble those which Van 



Fig. 110. —Blastodermic Vesicle of 
Bat (Van Beneden). X 275. 

C., cavity of vesicle; C.M., internal cell 
mass; E., enveloping layer. 


116 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


Beneden has demonstrated in the bat. In that animal the internal cell 
mass forms a lenticular enlargement upon the inner surface of the 
blastodermic vesicle. By the degeneration of the cells in its center and 
by the accumulation of fluid a cavity appears, which constitutes the 
amnion, while the embryonic area is developed from the cells at its base 
(Figs. 116, 117 and 118). Indeed, the only serious argument against 



Fig. 117. — Blastodermic Vesicle of Bat (Van Beneden). X 200. 
C.M., cell mass; Ed., ectoderm; Ent., entoderm; Y.S., yolk sac. 


such a supposition consists in relative paucity of mesoderm, which is so 
conspicuous a feature in the earliest human ova. 

As the earliest stages of development have not been observed in 
monkeys, no clue can be derived from that source, but the early ova 
described by Selenka bear a striking similarity to human ova of the 
third and fourth weeks, and likewise indicate that in that species the 


Ect. 



Fig. 118.— Bat Ovum (Van Beneden). X 200. Showing Amnion and Embryonic Area. 

Am., amnion, ( ., coelom; Ch., chorion; E.A., embryonic area; Ed., ectoderm; Ent., 

entoderm; Y.S., yolk sac. 


amnion and embryo do not originate as in the chick or the rabbit. Thus, 
Fig. 119, which represents a section through an early ovum of the 
gibbon, shows a well-developed chorion and ccelomic cavity, while the 
small embryo is suspended in the latter by a pedicle arising from the 
inner surface of the chorion. 

As has already been stated, the earliest human ovum with which we 
are acquainted was described by Miller in 1913. It was accidentally 













FORMATION OF THE CHORION AND AMNION 


117 



discovered in material removed from the uterus by curettage for 
hemorrhage twenty days after the last menstrual period, and was esti¬ 
mated to be ten or eleven days old. It measured 0.83 mm. in its great¬ 
est diameter and consisted of a mesodermic core 0.44 mm. in diameter 
surrounded by a thick 
trophoblastic capsule, which 
was actively invading the 
surrounding maternal tis¬ 
sue. Slightly basal to its 
center was a mass of ecto¬ 
dermal cells, measuring 
0.095 by 0.072 millimeter, 
which Miller interpreted as 
the amnion and embryonic 
shield. No sign of a yolk 
sac was observed, and as 
only a single well preserved 
section was available for 
study it would perhaps be 
hazardous to attempt to 
draw sweeping conclusions 
from it, but at the same 
time the ovum appears to be 
normal and to represent the 
youngest one described up 
to this time. 

Whether the credit of 
being the second earliest hu¬ 
man ovum belongs to the 
specimen of Linzenmeier or 
that of Bryce and Teacher 
is a matter of doubt. The 
former is definitely smaller 
than the latter, but at the 
same time presents a 
slightly more advanced stage 
of development. It was very 
well preserved and occupies 
a place midway between the 
specimens of Miller and 
Peters; while there is some 
doubt as to whether that of 

Bryce and Teacher is entirely normal, and for that reason the former 
will be first described. 

Linzenmeier’s ovum was found in a uterus removed on account of 
hemorrhage from a woman who had been curetted one month previously. 
It was imbedded in the decidua and measured 1.04 X 0.9 millimeters 
(Plate IV A, Fig. 8). It consisted of a chorionic membrane with actively 
proliferating trophoblast and a few rudimentary villi. The cceclomic 


Fig. 119.—Section through Young Ovum Or' 
Hylobates, showing Formation of Amnion 
(Selemka). X 8. 

A., amnion; a., amniotic pedicle; B., blood vessel 
C., chorion; C.V., chorionic villi; D., decidua 
E., embryo; I., point of inversion of blastodermic 
vesicle; Int., intervillous space, Y.S , yolk sac. 








118 


MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 



cavity was traversed by numerous mesodermic strands, and at its basal 
portion, broadly attached to the connective tissue of the chorion, were two 
cavities surrounded by mesoderm; a larger one corresponding to the 
amnion and a smaller one to the yolk sac. On one side of the amniotic 
cavity was an embryonic shield made up of several layers ot ectoderm 
and measuring 0.21 X 0.15 millimeter, but showing no sign of a primi¬ 


tive groove. (Fig- 120.) 




Bryce and Teacher’s ovum was described in 1908; was found in 
a shred of decidual tissue expelled eleven days after a menstrual period 
should have begun; measured 1.95 X 0-95 millimeters, and was estimated 

to be 13 or 14 days old (Fig. 115 and Plate IV B, Fig. 9). It consisted 

of a vesicle tilled with 

mesodermic tissue, which 
contained two small cavi¬ 
ties, each lined by a single 
layer of cuboidal cells, 
which were interpreted as 
the amnion and yolk sac, 
respectively. The outer 
wall of the vesicle was 
composed of several layers 
of ectodermal cells, pre¬ 
senting all stages of cell 
division, while springing 
from its periphery were 
irregularly shaped, branch¬ 
ing and interlacing masses 
of vacuolated protoplasm, 
not divided into individual 
cells, and which extended 
to the margins of the im¬ 
plantation cavity, opening 
up maternal vessels, whose 
contents had escaped into 
the meshes of the proto¬ 
plasmic network. The 
trophoblastic capsule was 
unusually extensive, and 
in view of its extraordi¬ 
narily open structure is 


Fig. 120. —Embryo from Linzenmeier’s Ovum at¬ 
tached to Chorionic Membrane, Highly Mag¬ 
nified, SHOWING AmNIOTIC CAVITY AND EMBRYONIC 
Area and Relatively Small Yolk Sac. 

A, chorionic ectoderm; B, amniotic cavity; C, em¬ 
bryonic area; D, yolk sac. 


not considered normal by many authorities. 

The next earliest ovum was described by Peters in 1899, and is of 
especial interest for the reason that its description afforded the basis 
for our present ideas concerning the mode of implantation of the ovum 
and the development of the chorion and amnion in man. It was found 
in the uterus of a woman who committed suicide three days after missing 
her menstrual period, and was originally considered to be only three or 
four days old, although it is now generally recognized as being two 
weeks older. It measured 1.6 X 9.8 X 9.9 millimeters in its various di- 







FORMATION OF THE CHORION AND AMNION 119 

ameters, and presented a well developed chorion with rudimentary villi 
inclosing a large ccelomic cavity, a very small amnion, an embryonic 
area and a yolk sac. Plate IV represents a section through the portion of 
decidua in which it was imbedded, and shows that the chorion is made up 
of two layers—a thin inner layer of connective tissue, to whose basal por¬ 
tion the amnion and embryonic area are broadly attached, and which 
forms the lining of the coelomic cavity, and an outer layer composed 
of many layers of ectodermal cells, in Peters’ opinion, this tropho¬ 
blastic capsule represented the primitive ectoderm of the ovum. The 
majority of its cells possess well-marked, rounded or cuboidal bodies 
with vesicular nuclei. Scattered between them, especially when in 
contact with maternal blood, are masses of protoplasm which show no 



- - -mes. 


-YS. 


mes. 


Fig. 121. —Portion of Peters’s Ovum, Highly Magnified, showing Early Stage in 

Development of Embryo.. 

A, amnion, C, chorion; ect., ectoderm; ent., entoderm; mes., mesoderm; E.S., embryonic 

shield; Y.S., yolk sac; Sp., portion of coelome. 


sign of division into individual cells, and contain irregularly shaped, 
darkly staining nuclei—syncytium. The trophoblast has deeply invaded 
the surrounding decidual tissue and has opened up numerous blood 
vessels, so that many large irregularly shaped spaces have developed, 
which contain maternal blood and represent the forerunners of the 
intervillous spaces of the fully formed placenta. From the connective 
tissue layer of the chorion, which is not yet vascularized, numerous small 
processes extend into the trophoblast and represent the earliest stages in 
the formation of chorionic villi. Fig. 121 is a highly magnified section 
through the amnion and embryonic area, and shows that the former 
is a mere flattened slit, and that the latter is made up of several layers 
of large ectodermal cells, which as yet show no signs of a primitive 
streak. 

In all early ova, which are approximately of the same age as Peters’ 








Fig. 122._Microscopic Section, showing Ovum Embedded in Decidua and Sur¬ 

rounded by Decidua Reflexa Probably 17 Days Old (Leopold). 



Fig. 123. —Section through early Human Ovum, showing Chorionic Vesicle, 

CONTAINING IN ITS INTERIOR THE CtELOMIC CAVITY AND THE MlNUTE EMBRYO, 
CONSISTING OF TWO CAVITIES UNITED BY MESODERM, THE LARGER BEING THE 

Yolk Sac and the Smaller the Amniotic Cavity with the Embryonic Area. 
(Streeter) X 25. 
















FORMATION OF THE CHORION AND AMNION 121 


specimen, the amnion and embryonic area are broadly attached to the 
basal portion of the inner surface of the chorionic membrane, or, in 


^Sr'N 

cdT ... \ 


other words, as far away from the uterine cavity as possible, with the 
apparent purpose of having the embryo attached at a point where the 
future maternal blood supply will 
be assured. This, however, is a 
transient condition; for, as the 
embryo becomes larger, its area of 
attachment becomes relatively nar¬ 
rower, becoming converted into a 
sort of peduncle—the abdominal 
pedicle or body stalk, the fore¬ 
runner of the umbilical cord, by 
which the embryo hangs from the 
chorionic membrane into the 
coelomic cavity (Figs. 127 and 
129). 

Moreover, while none of the 
early ova are entirely spherical, 
they tend to become lenticular in 
outline with increasing age, so 
that by the end of the fourth 
week the longitudinal diameter 
greatly exceeds the vertical, as is 
seen by comparing Figs. 122 and 
chansre in the relative size of 


Fig. 126.—Wax reconstruction of Mol- 
lendorf’s Ovum, with part of Amnion 

REMOVED, SHOWING EMBRYONIC AREA 

with Primitive Streak. X 100. 

A., chorionic membrane with villi; B-C., 
amnion; D., embryonic area with primi¬ 
tive streak. 


123. Likewise, there is a marked 
the yolk sac. In very early ova it is 
smaller than the amnion and embryonic area, but within a short time, 


Fig. 125. —Wax reconstruction of Mol- 
lendorf’s Ovum in Sagittal Section, 
showing Embryo attached to Chori¬ 
onic Membrane. X 100. 

A., chorionic ectoderm; B, chorionic meso¬ 
derm; C., roof of amnion; D., amniotic 
cavity; E., embryonic area; F., Ento¬ 
derm of yolk sac; G., mesodermal cover¬ 
ing of yolk sac. 


Fig. 124. —Wax Reconstruction of Mol- 
lendorf’s Ovum, showing early Em¬ 
bryo Attached to Chorionic Mem¬ 
brane and Projecting into the 
Ccelomic Cavity. 

A., chorionic membrane; B., body stalk; 
C., embryo surrounded by mesoderm. 






















122 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


the relations become reversed, so that it becomes so large that the 
amnion and embryonic shield sit upon it as a mere protuberance (Figs. 
128 and D30). This, however, is a transient phenomenon, as the in¬ 
crease in size soon ceases, while the embryo continues to grow, so that 
at the end of pregnancy the yolk sac constitutes only a minute fraction 
of the entire product of conception. It is, however, important to re¬ 
member that, aside from the chorion, the yolk sac is the most imposing 
constituent of the early ovum during the third and fourth weeks of 
development, which must indicate that at that time it .fulfills some im¬ 
portant function. 

In the early ova thus far considered, the embryonic shield is merely 


ABC DEF AB 



Fig. 127.— Median view of wax reconstruction of Mateer Ovum, showing the 
Amniotic Cavity and its relations to Chorionic Membrane and Yolk Sac 
(Streeter) X 50. 

A., chorionic villi; B., chorionic membrane; C , Body-stalk with allantois; D., flattened 

amniotic cavity; E., embryonic area; F., yolk sac. 


a smooth plate of ectodermal cells, which are continuous at the margins 
with the flattened cells which line the interior of the amnion. The 
first change indicative of the formation of the embryo is the appearance 
of the primitive groove towards the latter part of the third week. This 
is well exemplified in Figs. 124 to 126, which represent reconstructions 
of Mollendorf’s ovum, and in Figs. 127 and 128 from Streeter’s ovum. 
The latter measured 9 X 8 X 3.5 millimeters and was obtained at opera¬ 
tion 11 days after the failure of menstruation to appear. Fig. 127 repre¬ 
sents a segment through the chorionic membrane, to which the embryo, 
consisting of the flattened amniotic cavity, the embryonic shield, and the 
relatively large yolk sac, is attached bv the abdominal pedicle, which 














FORMATION OF THE CHORION AND AMNION 123 

contains in its interior a tubule lined by entoderm, which represents 
all of the allantois that is formed in man. Fig. 128 represents a 
frontal view of the same ovum, showing the large yolk sac, with the 
embryonic plate resting upon it and outlined by the cut edges of the 
amnion. The primitive groove extends forward from the cut end of 
the abdominal pedicle 01 body stalk. T hese specimens once more empha¬ 
size the fact that in man the amnion cannot originate from folds of 
the somatopleure as in the chick. 

Another ovum from the third week, described by Graf Spee, serves 



/VS 


Fig. 128. — Frontal view of Ovum shown in Fig. 127, Shield-shaped Em¬ 
bryonic Area, with Primitive Groove, resting upon the relatively large 
Yolk Sac. The band-like structure bounding the Embryonic area 
represents the basis of the Amnion, whose major portion has been cut 
away. The structure at the more pointed extremity of the Amnion repre¬ 
sents THE SEVERED BODY-STALK, WITH THE ALLANTOIS IN ITS CENTRE (Streeter). 

X 50. 

to confirm the views just stated concerning the formation of the amnion. 
This ovum measured 6 X 4.5 millimeters, and possessed a chorion with 
well developed villi, a portion of which is shown in Fig. 129. Projecting 
from its interior by the abdominal pedicle is a small vesicular structure 
—the beginning embryo. 

Fig. 130 represents a cross section through it, and shows clearly 
the relations of .its various parts. The embryo is attached to the inner 
surface of the chorionic membrane by the abdominal pedicle, and its 
greater portion is occupied by the yolk sac, from one end of which a 
small process, lined by entoderm, which must be considered as a rudi¬ 
mentary allantois, extends into the pedicle. Occupying one side of the 





124 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 





pedicle is a small cavity lined by a single layer of epithelium, which 
represents the amnion. On one side of this, again, is a mass of cells 
arranged in several layers—-the embryonic area, in which a primitive 
streak can be distinguished. Fig. 131 represents a highly magnified 
section through the same ovum, and shows that the three germ layers 


\' N c. e. 
s ' c.m. 







Fig. 129.— Spee’s Human Ovum, Embryonic Area. 0.4 Millimeter long. X 24. 

A., amnion; Bs., abdominal pedicle; C., chorion; c.e., chorionic epithelium; c.m., 
chorionic mesoderm; V., chorionic villi; Y., yolk sac. 


are well developed, each of which, w r ith the exception of the entoderm, 

consists of several lavers of cells. 

«/ 

Figs. 132 and 133 represent an older ovum with an embryonic area 
2 millimeters long, which was also described by Graf Spee. The embryo 
is attached to the inner surface of the chorion by the abdominal pedicle, 
and is made up in great part of the yolk sac. The embryonic area is 
oval in shape, and presents a definite medullary groove and primitive 



Fig. 130.—Section through Spee’s Ovum, shown in Preceding Figure. X 24. 

c., chorionic membrane; ect., ectoderm; mes., mesoderm; am., amnion; e., beginning 
embryo; bs., abdominal pedicle; all., allantois; y.s., yolk sac. 


streak. The two are not in the same plane, but the latter is bent almost 
at right angles to the former and occupies the inferior end of the em¬ 
bryonic area. Between the two is a small opening, the neurenteric canal, 
which serves to connect the ectoderm with the entoderm. Fig. 133 
represents a section through the same ovum, and shows a well-developed 
chorion with typical villi, while the amnion is a small sac closely applied 
















DEVELOPMENT AND ANATOMY OF THE PLACENTA 125 

>ver the beginning embryo. A highly magnified cross section (Fig. 
134) shows the three germ layers and a well-developed somatopleure and 
splanchnopleure. By the folding in of the former it is readily under¬ 
stood how the body walls are formed, and by that of the latter how 
;he primitive gut becomes differentiated from the yolk sac. 

Development and Anatomy of the Placenta.—The placenta may he 
defined as the organ by which intimate union is effected between the 
mucosa of the maternal generative tract and the embryonic adnexae, 
particularly the chorion, for the purpose of facilitating the transfer 



E.A., embryonic area; P., primitive streak; cct., ectoderm; cut., entoderm, vies., meso¬ 
derm. 

of the nutritive material from the mother to the foetus, and of excre- 
mentitious material in the reverse direction. 

In the various species of animals the placenta exhibits such pro¬ 
nounced differences in the mode of union between foetal and maternal 
tissues, in intimate structure, and in gross appearance, that it is safe to 
say that no other organ in the animal economy, which serves a single 
function, presents such marked variations. For example, the liver or 
kidney is practically identical in all mammalia, yet the placenta of swine 
pig differs so radically from that of the guinea pig that the casual 
observer would hesitate to conclude that he had to deal with the same 
oro-an were it not obvious that it serves a simliar function in each 










126 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


1 

animal. For this reason, it is unsafe to apply to a given animal con¬ 
clusions which have been drawn from the study of the placenta of any 
other species, even though closely related. Consequently, in considering i 
the development and anatomy of the human placenta, it is essential that 

our conclusions he based entirely 
upon the study of placentation in hu- • 
man beings. Unfortunately, many of 
the stages necessary to its complete 
elucidation have not yet been ob¬ 
served, and, until they are available, 
it would seem advisable, before tak¬ 
ing up the study of the developing 
and of the mature placenta, to con- | 
sider separately certain points con- j 
cerning the anatomy of its compo- ' 
nent parts—chorion, amnion and 
decidua. 

A. Structure of the Chorion.— 

In its very earliest stages the chorion : 
probably consists of the single ! 
layer of ectodermal cells forming the 
wall of the blastodermic vesicle 
(Fig. 4, 5 and 6, Plate IV A). Soon 
after the implantation of the ovum, 
however, as shown by the researches 
of Hubrecht, Huekelom, Peters and 
all subsequent investigators, the 
chorionic epithelium rapidly prolif¬ 
erates and invades the surrounding 
decidual tissue, forming the many¬ 
layered trophoblast. In its earliest 
stages the external surface of the chorion is probably smooth, but in a 
short time buds from its connective tissue lining make their way into 
the trophoblast and give rise to rudimentary villi (Plate IV). 

Fig. 137 represents a section through the periphery of a three or 
four weeks’ pregnancy. In the chorion can be distinguished two portions 
—the chorionic membrane, and the villi projecting from it. The mem¬ 
brane consists of two days layers—the inner of connective tissue, the 
outer of epithelium. The former is composed of spindle- and star¬ 
shaped cells embedded in a mucoid intercellular substance, and at this 
period does not contain blood vessels. The latter is arranged in two 
layers; an inner, adjoining the connective tissue, which is composed of 
cuboidal or roundish cells with clear protoplasm and lightly staining 
vesicular nuclei, and an outer layer made up of coarsely granular 
protoplasm, which shows no signs of division into cells, and through 
which are scattered irregularly shaped, darkly staining nuclei-syncytium. 

Each villus arises from the chorionic membrane as a single stem, 
which soon gives origin to numerous branches which assume an arbo¬ 
rescent form, the complexity of which increases with advancing age. 



Fig. 132.—Human Embryo 2 Milli¬ 
meters Long (Graf Spee). X 30. 

Am., amnion; C., chorion; C.V., 

chorionic villi; Bs., Bauchstiel; 
Mg., medullary groove; Nc., 

neurenteric canal; P.s., primitive 
streak; Y.S., yolk sac. 






STRUCTURE OF THE CHORION 


127 




The villi consist of a connective-tissue stroma and an epithelial covering, 
each of which is continuous with the corresponding tissue of the chorionic 
membrane. 

Projecting here and there from the surface of the villi are epithelial 



Fig. 133. — Section through Human Ovum, shown in Fig. 130 (Spee). 

all., allantois; c.e., chorionic epithelium; c.m., chorionic mesoderm; Bs., abdominal 
pedicle; E., beginning embryo; ent., entoderm; n.c., neurenteric canal; p.s., 
primitive streak; V., chorionic villi; ves., vessels in wall of yolk sac. 


Fig. 134. — Section through Spee’s Ovum, shown in Fig. 130. 

Am., amnion; ect., ectoderm; mes., mesoderm; ent., entoderm; M., medullary groove. 

buds, consisting of syncytium, and which, when seen in cross or 
tangential section, resemble giant cells. These buds indicate prolifera¬ 
tion of the outer layer of the chorionic epithelium, and may represent 
the first stage in the development of new villous branches, lleie and 














128 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 




Fig. 137. —Section through Three Weeks’ Human Ovum, showing Chorion, 

Decidua, and Intervillous Spaces. 

B.V., maternal blood vessel; C.M., chorionic membrane; D. } decidua; G., uterine gland; 
I.S., intervillous space; S., syncytium; T., trophoblast; V., villus. 

ceived a connective-tissue core, and thus have not been converted into 
villi. 

In early ova, the embryo is connected with the connective-tissue layer 
of the chorion by a mesodermic structure, which was first described by 


there, in the spaces between the villi, larger or smaller masses of small, 
clear cells with vesicular nuclei are seen. They were formerly described 


Fig. 135. —Early Human 
Ovum (Leopold). 


Fig. 136. —Three Weeks’ Human Ovum (Leopold) 


as decidual islands, and were supposed to represent sections through 
decidudl septa, which projected upward toward the. chorionic membrane. 
In reality, however, they are masses of trophoblast which have not re- 


CLM. 







STRUCTURE OF THE CHORION 


129 


His as the abdominal pedicle or body stalk, and is the forerunner of the 
umbilical cord. Through this the umbilical vessels of the embryo 
eventually make their way to the chorionic membrane and there fuse 
with blood vessels which have originated in situ. In this way, the foetal 
circulation gains access to the villi, and makes possible the exchange of 
substances between the maternal and foetal blood. 

In early pregnancy the villi are pretty equally distributed over the 
periphery of the chorionic membrane, but later they become more 
abundant over the portion which is in contact with the decidua basalis, 
the site of the future placenta. This portion is designated as the chorion 
frondosum, while the remainder, which is in contact with the decidua 
capsularis, is termed the chorion laeve, since the villi covering it even¬ 
tually undergo complete degeneration. 

A certain number oi villi extend from the chorionic membrane to the 
underlying decidua, attaching the ovum to it, and hence are designated 
as fastening villi. The majority, on the other hand, are arborescent 
structures, whose free endings do not reach the decidua. In early 


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Fig. 138. —Chorionic Vil¬ 
lus, Third Week. X 
225. 


Fig. 138A. — Chorionic 
VillusatFourth Month. 
X 225. 


Fig. 138B. —C horionic 
Villus at Term. X 225. 


pregnancy the villi are short and plump and represent simply the main 
stems, but later they give off numerous branches and assume an arbo¬ 
rescent appearance. Thus, sections through a young chorion show only 
a few large villi, while those through an older one are filled with a 
multitude of smaller branches. This change in appearance may be 
compared to what takes place in a clump of trees, which at an early 
period consists of a number of almost isolated trunks, each of which 
later gives off innumerable branches and twigs. These differences have 
been particularly emphasized by I)e Loos, who has shown that with a 
little practice one can roughly estimate the age of the chorion by its 
appearance on section. 

The stroma of the villi also varies in appearance according to the age 
of the chorion. In the earlier stages the cells arc branching in shape, and 
are separated from one another by a large amount of mucoid intercellular 
substance; later on they become more spindle-shaped and more closely 
packed together, so that the stroma assumes a denser appearance (Fig. 
138). Another type of cell also occurs in the stroma the so-called 
plasma or Hofbauer cell. These are roundish cells with vesicular nuclei 





130 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


and very granular or vacuolated protoplasm. In fresh specimens \\ arren 
H. Lewis has shown that their granules stain so characteristically with 
vital stains that he is inclined to classify them as plasmatocytes, but 
at the same time there is some evidence that they may represent Lang¬ 
hans’ cells which have wandered into the stroma. They are present in all 
stages of pregnancy, but are most abundant during the early months, and 
particularly when the foetus is defective. After the third week, but 
before there is any sign of the foetal heart, blood islands appear in the 
mesodermic tissue of the chorion, and vascular walls soon appear around 
them. These coalesce to form larger vessels, and soon lead to complete 
vascularization of the chorion and its villi. It is important to re¬ 
member that in man these vessels originate in situ, and are not derived 
from the allantois, as is often taught. The villous vessels soon become 
very abundant, and in the later months of pregnancy almost displace 
the stroma. The arteries and veins extend to the tips of the villi, 
where they break up into capillaries, but there is no anastomosis between 
the vascular supply of the various villi, any more than between the 
branches of different trees in a forest. 

The epithelium covering the villi was mentioned by Dalrymple in 
1842, but was first definitely described by Langhans many years later. 
The latter pointed out that it was made up of the two layers already 
described (Fig. 138). The inner he designated as the cell-layer (Zell- 
schicht), although it is now generally known by his name; while the 
outer layer is described as the syncytium. This latter term was in¬ 
troduced in 1893 by Kossraann and Merttens, although the characteris¬ 
tics of the tissue had been recognized years before by Kastschenko, who 
designated it as plasmodium. 

During the first half of pregnancy the two layers are readily dis¬ 
tinguished, but later Langhans’ layer becomes more and more indis¬ 
tinct, so that during the second half the villi are covered only by a 
single layer of syncytium. Figs. 138 to 138 B give a good idea of the 
successive changes in the stroma and epithelium at different ages. Care¬ 
ful examination of properly prepared specimens shows that the syncytial 
layer presents a vacuolated structure, and that its outer margin does not 
present a smooth surface, but is made up of a vertically arranged 
pseudopodialike protoplasmic process. These structures are too coarse 
to be considered as cilia, and are designated by Marchand, Bonnet, Hof- 
bauer, and others as bristlelike processes. 

The origin of the two layers of chorionic epithelium has given rise to 
a great deal of discussion, but it has been established by the work of 
Langhans, Kastschenko, Minot, Webster, Heukelom, His, Ruge, Peters, 
as well as by all recent investigators that they are both ectodermal in 
origin, and are derived from the original trophoblastic covering of the 
ovum. 

In 1893 Kossmann advanced the theory that the syncytium was 
derived from the epithelium of the uterus, while only Langhans’ layer 
represented the original ectoderm, which was apparently confirmed by 
Merttens. This work was very plausibly set forth and accompanied by 
numerous excellent illustrations, so that the conclusions of Kossmann 



STRUCTURE OF THE AMNION 


131 


and Merttens were soon adopted by many authorities. This view is now 
regarded as untenable, inasmuch as all recent investigators have shown 
that the ovum is surrounded by the many-layered trophoblast before 
the formation of the villi begins, and that the syncytium represents only 
a modification of it. Still more convincing evidence against its uterine 
origin is afforded by our present knowledge covering the mode of im¬ 
plantation of the ovum (Plate IV A and B). Consequently, it may be 
positively stated that the syncytial layer is not of maternal origin, and 
that such a view is a relic of old and discarded theories concerning the 
implantation of the ovum. 

The theory of Kossmann and Merttens is only one of a large number 
which have been advanced in explanation of the origin of the chorionic 
epithelium. Those who are interested in the subject are referred to the 
article of Waldeyer, who in 1890 was able to arrange in ten groups tho 
numerous theories which had been advanced up to that time. In 1916 
de Kervily studied mitochondrial formation in the chorionic villi, and 
his article represents a storehouse of information concerning all points 
connected with the minute anatomy of the chorion. 

B. Structure of the Amnion.—In the very earliest stages of preg¬ 
nancy, as we have already shown (Fig. 110), the amnion is a minute 
vesicle; later it forms a small sac which covers only the dorsal surface 
of the embryo, and eventually becomes larger and completely surrounds 
it. At first the amnion occupies only a minute portion of the entire 
ovum; but as pregnancy advances it increases in size, until eventually 
it comes in contact with the interior of the chorion and obliterates the 
extra-embryonic portion of the coelom. V hen the outer surface of the 
amnion has supplied itself to the inner surface of the chorion, the two 
membranes become slightly adherent, but are never very intimately 
connected, for even at the end of pregnancy they can be readily separated 
from one another. 

From its earliest stages the amnion consists of two layers: an outer 
layer of mesoderm and an inner layer, made up of cuboidal or flattened, 
ectodermal cells. The mesodermic layer eventually becomes com cited 
into mucoidlike tissue, which does not contain blood vessels; while tin; 
ectodermal portion is represented by a single layer of cuboidal epithelial 
cells, vdiich by their origin are homologous with the cells making up the 
embryonic shield, and hence may be regarded as simply an extension 
of the skin of the embryo. This relationship is accentuated by the fact 
that in somewdiat more than one-half of all placentae, at term, small, 
rounded placques may be observed upon the amnion, particularly in 
the neighborhood of the attachment of the umbilical cord. Upon 
microscopical examination they are found to be made up of stratified 
epithelium, which bears a close resemblance to that of the skin. They 
are designated as amnionic caruncles, and will be considered moie full} 

in the chapter on the »pathology of the ovum. 

Soon after its formation, a certain amount of clear fluid collects 
within the amniotic cavity—the amniotic fluid which increases in 
quantity as pregnancy advances. The amount varies within wide limits, 
and according to Fehling averages about 600 cubic centimeters at die 





132 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 



end of pregnancy, although under abnormal conditions it may vary from 
a few cubic centimeters to many liters. Its specific gravity ranges from 
1.002 to 1.028, and it contains a certain amount of albumin, urea, 
kreatin, and various salts. Its origin and function will be considered 
when we take up the physiology of the foetus. 

C. Decidua.—The decidua is the mucous membrane of the uterus 
which has undergone certain changes under the influence of the ovulation 

cycle, to fit it for 
the implantation 
and nutrition of the 
ovum. It is so 
named from the 
fact that it is cast 
off after labor. 

The conversion 
of the uterine 
mucosa into decidua 
occurs shortly after 
the fertilization of 
the ovum, though 
we are unable to 
state exactly when 
the process com¬ 
mences, inasmuch 
as the premenstrual 


Fig. 139. —Uterus lined by Decidua, containing an Early 

Ovum (Leopold). X 1. 


swelling is accom¬ 


panied by marked 
changes in structure, which must be regarded as pregravid or predecidual 
in character; but more particularly because a fairly well-marked decidua 
was present in all of the early pregnancies which have thus far been 
described. 

After conception the hypertrophic premenstrual endometrium be¬ 
comes still thicker and eventually attains a thickness of from 5 to 10 
millimeters, while its surface becomes indented by furrows of consider¬ 
able depth, which give the entire membrane a mamelonated appearance. 
Under the magnifying-glass numerous small openings can be distin¬ 
guished which are the mouths of the uterine glands. The decidual 
formation is limited to the body of the uterus, and does not extend 
below the internal os, though in rare instances, as in the cases reported 
by von Franque, von Weiss, Yolk, Lynch, and others, isolated decidual 
cells are found beneath the cervical epithelium. 

For purposes of description the decidua is usually divided into three 
portions: that lining the main cavity of the uterus being designated 
as the decidua vera; that beneath the ovum as the decidua basalis or 
serotina; while the portion which surrounds the. ovum and shuts it off 
from the rest of the uterine cavity is known as the decidua capsularis or 
reflexa. 

The terms reflexa and serotina date from the time of William Hunter, 
who gave excellent drawings of the decidual membrane in his atlas. 







DECIDUA 


133 


Jnfortunately, the explanatory text, was prepared by John Hunter and 
Jatthew Baillie, who considered that the decidua represented a fibrinous 
xudate from the lining membrane of the uterus, which formed a com- 



Fig. 140. 

Figs. 140, 141. —Diagrams illustrating 

Decidua 


Fig. 141. 

Hunterian Theory of Formation of 
Reflexa. 




Fig. 142. 


plete cast of its cavity and covered the tubal openings. They supposed, 
therefore, that when the ovum reached the uterine end of the tube its 
further passage was opposed by the decidua vera, which it was obliged 
to push before it as it entered the uterus, whence 
the term reflexa; and that, after the latter had 
been pushed forward, a new exudate was de¬ 
veloped behind the ovum, to which the term 
serotina was applied (Figs. 140 and 141). 

This conception was universally accepted until 
1846, when Weber in Germany and Sharkey in 
England demonstrated that the decidua contained 
uterine glands, and consequently muse be the 
altered endometrium. It having therefore become 
necessary to explain the formation of the reflexa 

in a different manner, it was assumed that the FiQg 142 , 143 .—D i a- 
ovum, on reaching the uterus, found its entire GRAM s illustrating 

cavity lined by decidua vera to some point of Ocd Theobv^Fo^ 

which it became attached; and that immediately Reflexa . 
afterwards the vera began to prolif eiate and to , 

form a wall around the ovum, until it had completely inclosed and 
surrounded it. Later investigation, in turn, showed that this view was 
not correct, as the ovum remains upon the surface for only a lew- hours, 
and then burrows into the depths of the decidua, as has already been 
described. Notwithstanding these new ideas, the terms reflexa an, 
serotina are still emploved. though in the new anatomical nomencla 
they are more properly' designated as the decidua capsulans and lasalis 

respectively. 














134 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 



Decidua vera.—The microscopic structure of the decidua vera was 
first studied by Hegar and Maier, but it was not until the work of 
Friendliinder, and Kundrat and Engelmann that its structure was defi¬ 
nitely understood. Friendlander in 1870 pointed out that the decidua 
vera was composed of two portions: a compact layer superimposed upon 
a spongy or glandular layer, the latter adjoining the muscular wall of 

the uterus, and 


compact 


forming the main 
thickness of the 
membrane. He 
showed that the 
compact layer was 
made up of large 
round, oval, or 
polygonal cells, 
with large, lightly 


staining, vesicular 


spongy 


nuclei — the de¬ 
cidual cells , while 
the spongy layer 
was composed of 
dilated and hyper¬ 
plastic uterine 
glands. Further¬ 
more, he formed 
the incorrect 
opinion that sep¬ 
aration at the time 
of labor took place 
at the junction be¬ 
tween the two 
layers. 

The decidua 


muscle 


vera increases 
markedly in thick¬ 
ness during the 
first three or four 
months of preg¬ 
nancy, so that at 
Fig. 144— Decidua Vera, Fourth Mofrni. X 16. the end of that 

time it may attain 

a thickness of about 1 centimeter. Figs. 51 and 144 show very 
graphically the difference between the normal endometrium and the 
decidua vera from a uterus four months pregnant. After the fourth 
month, owing to the distention of the uterus, the vera gradually be¬ 
comes thinner, so that at term it is rarely more than 1 or 2 millimeters 
thick. 

Under the microscope the compact layer is seen to be made up of 
somewhat closely packed, large, oval, or polygonal cells, which are dis- 




















DECIDUA VERA 


135 


tinctly epithelioid in appearance, and possess round, vesicular nuclei, 
which stain but slightly with the ordinary reagents. When the tissue 
has been distended by hemorrhage or edema, it is seen that many of the 
decidual cells present a stellate appearance, and are provided with long 
protoplasmic outgrowths which anastomose with similar processes from 
neighboring cells. Particularly in the early months of pregnancy, one 
sees scattered between the typical decidual cells a considerable number 
of small round cells, whose bodies are almost entirely filled by the 
nucleus. Such cells were formerly considered as lymphoid in character, 
but Marchand and Rossi-Doria contend that they are forerunners of 
new decidual cells, basing their contention upon the fact that they 
frequently contain mitotic figures, and that all gradations may be ob¬ 
served between them. In the early months of pregnancy the ducts of 



Fig. 145. —Decidua Vera, Fourth Month. X 420. 

the uterine glands may be seen traversing the compact layer, but they 
soon disappear, so that in the later months all trace of them is lost. 

The spongy layer is made up of the distended and hyperplastic glands 
of the endometrium, which are separated from one another by a minimal 
amount of stroma. In many instances the glandular hypeiplasia is so 
marked that the spongy layer suggests an adenoma in appearance. At 
first the glands are lined by typical cylindrical uterine epithelium, 
which presents evidence of abundant secretory activity. Ihe mateiial 
secreted probably serves as a pabulum for the ovum pending the estab¬ 
lishment of the placental circulation. Later the epithelium gradually 
becomes cuboidal, or even flattened, in shape and, undergoing fatty de¬ 
generation, is cast off in great part into the lumina of the glands. A 
certain amount of epithelium, however, remains intact throughout pi eg 
nancy, and from it the endometrium is regenerated after labor. Par¬ 
ticularly, toward the muscular is, the stroma between the dilated glands 

















136 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


undergoes but little change, and closely resembles that of the non¬ 
pregnant uterus. 

Under the influence of pregnancy, the surface epithelium covering 
the decidua soon loses its cylindrical shape and becomes cuboidal or 
flattened, sometimes even resembling endothelium. Klein first directed 
attention to this changed condition, and subsequently all observers have 
held that it is a characteristic microscopic evidence of pregnancy. 

Fig. 145 represents a section through the compact layer of the 
decidua vera at the fourth month, while Fig. 146 shows a gland with its 
surrounding stroma from a non-pregnant endometrium, drawn under 
the same magnification. On comparing them, it is readily seen that the 
decidua differs from the latter by a marked increase in size of the 
stroma cells, and a decrease in size of the epithelial cells. Schick in 





I i<j. 146. Gland and Stroma from Non-pregnant Endometrium. X 420. 

1.6).) pointed out that the decidua is particularly rich in lymphatic 
spaces, and holds that in properly prepared specimens they occupy at 
least as much space as the hypertrophied glands. 

As a lesult of the work of ILegar and Maier, Leopold, Minot, and 
others, it is now universally held that the decidual cells are derived from 
fhc stroma cells of the endometrium, which have undergone marked 
increase in size, but only slight increase in number. Ruge directed 
attention io the resemblance which they bear to sarcoma cells, and 
stated that “the decidual cell represents the physiological tvoe of the 
sarcoma cell.” J 

The connective-tissue origin of the decidual cell was established only 
after prolonged investigation, and, before it was definitely proved, vari¬ 
ous theories were advanced as to their origin: Hennig believing that 
they were derived from leukocytes, Frommel and Overlach from the 










DECIDUA VERA 


137 


uterine epithelium, and Ercolani from the endothelium of the blood 
vessels. At the present time these views are of interest only from an 
historical standpoint. 

The connective tissue origin has been further confirmed by obser¬ 
vations made in certain specimens of early tubal pregnancy, in which 
decidual cells may be seen developing in the smaller folds of the mucosa 
of the opposite non-pregnant tube. In such circumstances, it is apparent 
that they are derived from the ordinary connective-tissue cells, and 
result from the hypertrophy of preexisting units rather than from their 
proliferation. Furthermore, Schmorl, Kinoshita, Hermann, and others 
have described, in women dying soon after childbirth, small nodules, 
varying from structures just visible to the naked eye to bodies 1 to 2 
millimeters in diameter, just beneath the peritoneum, covering the 
posterior surface of the uterus, Douglas's culdesac, the anterior surface 
of the rectum, and occasionally also over the ovaries. Schmorl considers 
that such nodules are always present at the end of pregnancy, and has 
demonstrated that they are made up of decidual tissue. Unterberger 
has succeeded in producing them experimentally by scraping the peri¬ 
toneum from the exterior of the uterus, thereby demonstrating that the 
cells composing them must be derived from connective tissue and not 
from the peritoneal epithelium. Outerbridge has described similar 
formations in the appendix, while Geipel has shown that they may be 
present in the omentum, and also that decidual cells frequently develop 
in the pelvic lymphatic glands from the tissue just outside of the vessels. 
I have also studied several specimens which showed an unusually wide 
distribution of decidual formation. In the most pronounced instance, 
the pregnant uterus was the seat of an adenomyoma, and typical de¬ 
cidual formation was noted in the interglandular tissue of the endome¬ 
triumlike areas far removed from the uterine cavity. Likewise, in 
cases of hydatidiform mole, distinct decidual formation was noted not 
only in the mucosa of the tubes, but also in the connective-tissue just 
beneath their peritoneal covering. 

Decidua capsularis.—Except for the first few hours after its entry 
into the uterus, the ovum is shut off from the rest of the uterine cavity 
by the decidua reflexa or capsularis, which forms a capsule of decidual 
tissue around it. Fig. 139 shows an early pregnancy in which the 
reflexa is quite apparent, and Fig. 147 a five or six weeks pregnancy 
in which it is well developed. 

During the early months of pregnancy the decidua capsularis does 
not entirely fill the uterine cavity, so that a space of varying size exists 
between it and the vera, This is well shown in Fig. 148, which repre¬ 
sents an eight weeks' pregnant uterus. At the fourth month of pieg- 
nancy, however, the growing ovum entirely fills the uterine cavity, so 
that the reflexa and vera are brought into intimate contact, and the 
part of the uterine cavity which had remained unoccupied up to this 
time becomes obliterated.* In a short time the two structures fuse to¬ 
gether, when the capsularis gradually degenerates and disappears. This 
view was first advocated by Minot, and appears to be well founded, inas¬ 
much as sections through the wall of the full-term uterus outside of the 






138 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUfl 



placental site show that the entire decidua is only 1 to 2 millimetei 
thick, and no indication of the decidua reflexa can be discovere 
(Fig. 153). 

The decidua capsularis usually attains its greatest thickness at abou 
the second month. Sections through it at this time show that it i 


^D.V. 


Fig. 147. I ive A eeks’ Pregnant Uterus. X 1 (Anatomical Museum, Johns Hop¬ 
kins University.) Embryo drawn relatively too large. 


kOCKWQOD, 

fee. 


D.S. 


D.U., decidua reflexa; D.S., decidua serotina; D.V., decidua vera; E., embryo; O.L., 

ovarian ligament; R.L., round ligament. 


made up of decidual cells and is covered on its exterior by a single layei 
oi flattened epithelial cells j while internally it is in contact with the 
foetal villi, and at no time shows any trace of uterine epithelium. In 
its lowest portion, where it is connected with the vera, a few glands 
may he found, whose ducts, when present, are seen to open only upom 
the outer surface of the membrane. 

Until recently it was universally believed that the capsularis origi- 

















decidua basalis 


139 


ate , d f rom Proliferation of the vera, which grew up around and 
rad "ally inclosed the ovum. More accurate knowledge concerning the 
lode of implantation of the ovum, however, shows that this is not, the 
ise, but that the capsularis is merely the portion of the decidua vera 
1 hich covers the ovum (Plates IY and TV A and B). 

Decidua basalis.—-The decidua basalis or serotina is the portion of 
le decidua w hich lies immediately beneath the ovum; from it the 



[G. 148. —Sagittal Section of an Eight Weeks’ Pregnant Uterus Slightly to 

One Side of the Midline. X 1. 

Specimen from the Department of Embryology of the Carnegie Institution.) Note the 
k early placenta on right and thick decidua vera on left side. The embryo lies in the 
amniotic cavity, outside of which is the chorion and the decidua capsularis. The 
remnant of the uterine cavity lies between the decidua vera and capsularis. 


Laternal portion of the placenta is developed. Broadly speaking, it 
r resents the same general structure as the decidua vera, except that it 
las been invaded by foetal tissue, so that its superficial portions are 
i imposed of foetal ectoderm, as well as decidual cells. 

Friedlander and Leopold stated in their original monographs that 
iant cells appeared in the basalis about the middle of pregnancy, 
'hese, they thought, made their way into the vessels and gave rise to 
j irombosis. Their interpretation, however, is no longer accepted, and 










140 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 

it is now known that the so-called giant cells are noi of decidual origin, 
but represent portions of trophoblast, which have invaded the decidua. 
Fig. 149, representing a section through the decidua basalis. in the 
last month of pregnancy, shows clearly that its superficial portions are 
composed of a mixture of both foetal and maternal cells. 

In the decidua basalis large numbers of blood vessels are observed 
The arteries pursue a spiral course, and usually penetrate the entir( 
thickness of the membrane ) while many of the veins become markedly 



F.ec. 

\ 

\ 

\ 

t 

i 

i 


F.ec. 

/ 

—i - 

/ 

i 

i 

i 


Fig. 149.—Decidua Basalis, showing Mixture of Fcetal and Maternal Cells. 

G., gland; V., vessel; F.ec., foetal ectoderm. 


X 71 




dilated and form large sinuses. In Fig. 149 two small vessels may 1 
seen which, after pursuing their course through the superficial layer c 
the serotina, open into the intervillous spaces of the placenta. Til 
consideration of the vascular connections between the foetus and tl! 
uterus, however, will be deferred until we take up the study of tl 
placenta. 

D. Development of the Placenta.—The mode of implantation of tl 
ovum has already been described, and it is generally believed that 
usually occurs upon the upper portion of either the anterior or posterk | 













DEVELOPMENT OF THE PLACENTA 


141 


wall >)f the uterus, and only exceptionally upon its lower portion. The 
ovum is very rarely implanted at the fundus or in the angles, since in 
these locations the decidual reaction is much less pronounced than else¬ 
where. After the ovum has burrowed into the depths of the decidua, 
t the portion separating it from the uterine cavity is known as the 
| capsularis, and that beneath it as the basalis. Almost immediately it 
i becomes converted into a blastodermic vesicle, whose outer ectodermal 
j covering, which is now designated as the trophoblast, at once begins to 
proliferate and invade the surrounding decidual tissue. As it does so, 
it breaks through the walls of maternal capillaries, from which the 
blood escapes and forms cavities, which are bounded partly by tropho¬ 
blast and partly by decidua (Plates IV and V). As the process goes on 
more vessels are opened up, so that in a short time the trophoblast 
j presents a sievelike appearance due to the presence of large numbers 
of blood spaces filled with'maternal blood. As a result, the trophoblastic 
cells become compressed into irregularly shaped masses of varying size, 
[ some of which extend from the surface of the ovum to the surrounding 
decidua, and afford the epithelial basis from which the villi are de¬ 


veloped. 

The maternal blood spaces established in this manner represent the 
earliest stages in the formation of the intervillous blood spaces of the 
future placenta, and are abundantly present in the early ova recently 
studied. Coincidentally with their formation, the trophoblastic masses 
are invaded by connective-tissue offshoots from the chorionic membrane, 
and are thus converted into villi, whose epithelial covering becomes 
arranged in two layers: the inner consisting of Langhans* cells and the 
outer of syncytium. 

As already indicated,- a considerable number of the pi ini ar} mill 
extend from the periphery of the chorionic membrane to the surrounding 
decidua, while the majority project freely into the blood spaces. Tin 
former are designated as fastening villi , and serve to attach the ovum 
to the decidua. Where they come in contact with the latter, the tropho- 
blast at their tips, which is now designated as chorionic epithelium, 
undergoes marked proliferation, and like the roots oI a tree invades the 
decidual tissue still further, until the two structures become firmly 
united. The proliferated trophoblast may be. observed m placentae 
in all stages of development, and is represented by what are usua.y 

known as the cell nodes or cell columns. . 

During the first few weeks of pregnancy branching vim project 

from the entire periphery of the ovum, as is well seen m Figs. L>o 
and 136 They come in contact not only with the decidua oasalis, but 
also with the capsularis, so that for a time intervillous blood spaces 
surround the entire ovum. As the chorionic villi are devoid of bioo< 
vessels for the first few weeks, the ovum must be nourished^ during that 

period by osmosis from the maternal fluids. 

As pregnancy advances, the blood supply of the decidua basalis be¬ 
comes more and more abundant, while that of the capsu ans cumins ins , 
as a consequence the villi in contact with the former are better nourished 
and grow more luxuriantly and take part m the formation of the 





142 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


placenta. Over the rest of the periphery of the ovum the villi develop 
less rapidly, and eventually atrophy, so that the portion covered by 
them becomes known as the chorion laeve. As the ovum increases in 
size, the intervillous spaces in the chorion laeve become smaller, and 
smaller, and by the fourth month, when the decidua reilexa has come 
in contact with the vera, they become obliterated, and the villi which 
project into them undergo degeneration, but do not completely dis¬ 
appear. For, even at term, sections through the uterine wall (Fig. 
153) show that the chorion laeve consists of several layers of epithelial 
cells, which represent the chorionic epithelium, through which are 
scattered round or oblong hyaline bodies, in which a few r spindle-shaped 
nuclei can be distinguished. These are the remains of the earlier villi. 
At the same time degenerative changes take place where the chorionic 
epithelium conies in contact with the decidual tissue, which result in 
the formation of a nbrinlike material which will be considered in detail 
a little later. On the other hand, the villi of the chorion frondosum 
increase in size and number, and the blood vessels which originated with¬ 
in them become connected with branches of the umbilical vessels of the 
embryo, so that after the first few weeks the foetal circulation extends to 
the tips of the smallest villi. 

The placenta is formed by the union of the chorion frondosum and 
the decidua basalis, and therefore is composed of both foetal and maternal 
tissues. 




It soon constitutes a distinct structure, although its site is 


indicated at a still earlier period by the point of attachment of the 
abdominal pedicle to the inner, surface of the chorionic membrane. Ac¬ 
cording to Benoist, its weight exceeds that of the foetus for the first 
three and a half months of pregnancy. 

One can probably best understand the structure of the placenta by 
studying sections through it at various periods of pregnancy. One from 
me fourth month#is reproduced in Plate VI, and shows that the organ is 
made up in great part of chorionic villi, whose stroma presents a some¬ 
what mucoid appearance, and contains spindle- and star-shaped con¬ 
nective-tissue cells, between which well-developed arteries, veins, and 
capillaries may be observed. At this stage the villous epithelium is 
arranged in two layers—Langhans’ layer and the syncytium—and from 
the latter many buds protrude, which, when examined in cross or 


tangential section, appear as giant cells lying free in the intervillous 
spaces. 

In the upper part of the plate is the decidua basalis, with which some 
of the fastening villi are' connected. At their ends can be noted a 
marked proliferation of ectodermal cells, which invade the underlying 
decidua, giving rise to the cell nodes or cell columns , and corresponding 
to the trophoblastic proliferation of the early days of pregnancy. The 
cell 4 nodes are composed almost exclusively of Langhans’ cells, as the 
syncytium does not follow them down into the depths of the decidua. 
The space between the chorionic membrane and the decidua, as well as 
between the villi themselves, is designated as the placental space. These 
intervillous spaces are fiTed with maternal blood and their vails are 
lined by syncytium. Scattered through them are isolated giant cells— 







PLATE Y. 






, -- 

* G.C. D.I. V 

SECTION THROUGH FOUR MONTHS’ PLACENTA, SHOWING JUNCTION OF 

CHORION AND DECIDUA. X 56. 

C. F., canalized fibrin; C. N. t cell nodes; D., decidua serotina; D. /., decidual island; 
G. C., giant cell /. S., intervillous space; P. .proliferating villous epithelium; \ ., 
chorionic villi. 










































































DEVELOPMENT OF THE PLACENTA 


143 


the so-called placental giant cells—whose origin has already been con¬ 
sidered. Here and there are seen a few large areas composed of cuboidal 
or polygonal cells with vesicular nuclei, which frequently present signs 
of degeneration. These are the so-called decidual islands, and were 
formerly supposed to represent sections through decidual septa, which 
projected upward from the surface of the decidua basalis toward the 
chorionic membrane. But, as has already been pointed out, this con¬ 
ception is erroneous ; as most of them represent masses of trophoblast, 

( into which the chorionic connective-tissue has not grown, and which 
therefore have not developed into typical villi. 

At the junction between the foetal and decidual tissue, areas are noted 
which stain deeply with eosin, and which, on closer examination, are 
seen to be made up of fibrinoid material, honeycombed in various direc¬ 
tions by small spaces —canalized fibrin. This results from the degen¬ 
eration of both foetal and the decidual cells, and is known as Nita- 
buchls fibrin layer, from the author who first called attention to its 
presence in the decidua. Its existence has been confirmed, and its 
characteristics have been studied by Langhans, Rohr, and others. It 
would seem that degenerative changes of this type occur wherever foetal 
and maternal tissues come in contact, and the phenomenon suggests 
that the function of the decidua is not merely to afford a suitable 
structure for the implantation and nutrition of the ovum, but also to 
protect the maternal organism against invasion by foetal cells. More 
particularly, as experience teaches that whenever the decidual reaction 
is defective or lacking the growing villi invade the maternal tissue al¬ 
most like a malignant growth, and lead to disastrous consequences, as 
in extra-uterine pregnancy and certain cases of rupture of the uterus. 

Until comparatively recently the participation of foetal tissue in the 
decidua basalis was not recognized. Furthermore, Winckler and other 
observers considered that the cells covering the maternal surface of the 
chorionic membranes were decidual in origin, instead of being chorionic 
epithelium as is now believed. They held that decidual tissue extended 
from the margins of the decidua basalis over the whole of the maternal 
surface of the chorionic membrane, so that the entire intervillous space 
was included between decidual or maternal tissue. "Winckler, accordingly, 
designated the superficial portion of the decidua as the basal, and the 
portion covering the chorionic membrane as the closing plate of the 
decidua. As it has already been shown that the tissue in question is 
composed of foetal ectoderm, the conception of decidual plates should be 

! abandoned. 

At present it is universally admitted that the blood in the intei- 
villous spaces is exclusively maternal in origin, and at one point (Plate 
V) a maternal vessel is seen which, after reaching the surface of the 
decidua, opens directly into them. At the point marked “P 9 in Plate 
Y, a villus is seen whose tip projects into the lumen of a uterine vein, 
and in many instances the ends of such villi grow for a consideiable 
distance into vessels. Yeit has pointed out that in such circumstances 
portions of villi may become broken off, and thus gain access to the 
general circulation. He designates the process as deportation, and 









144 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 



—Decidua 


—Chorionic 
villi and 
Intervillous 
spaces. 


-Chorionic 

membrane 

-Amnion. 


'U Y\, 


Fig. 150.—Section through Placenta at 
Eighth Month. X 15. 


upon it has constructed 
an extensive theory con¬ 
cerning many of the ab¬ 
normalities of preg¬ 
nancy, to which refer¬ 
ence will later be made. 

The foetal blood in 
the vessels of the 
chorionic villi at no 
time gains access to the 
maternal blood in the 
intervillous spaces, the 
two being separated 
from one another by the 
double layer of chor¬ 
ionic epithelium, a por¬ 
tion of the stroma of 
the villus, and the ves¬ 
sel walls. 

Structure of Pla¬ 
centa in Latter Half of 
Pregnancy and at Full 
Term.—Except in its 
increased size, the pla¬ 
centa in the second half 
of pregnancy differs but 
slightly from that of the 
fourth month. Micro¬ 
scopic sections at this 
period, however, show 
certain points of differ¬ 
ence. These are well 
illustrated in Fig. 150, 
which represents a sec¬ 
tion through a seven 
and a half months pla¬ 
centa and the adjacent 
decidua. Studying it 
from below upward, we 
see that it is composed 
of the following struc¬ 
tures : amnicn, chori¬ 
onic membrane, villi, in¬ 
tervillous bicod spaces, 
and decidua basalis. 

The amnion covers 
the inner or foetal sur¬ 
face of the p acenta, and 
consists o. a single 






















PLATE VI 





O TvX V g U. * 


'terminal chorionic villus, 


WITH INJECTED VESSELS. 


( 


j 

( 


1 



STRUCTURE OF PLACENTA 


145 


layer of cuboidal epithelium, below which comes a layer of more or less 
fibrillar connective-tissue, containing no blood vessels. The chorionic 
membrane presents essentially the same structure as in the earlier months 
of pregnancy, differing only in the presence of a large amount of canal¬ 
ized fibrin immediately beneath its epithelium, as well as in the presence 
of larger vessels. 

The great bulk of the placenta is made up of chorionic villa, whose 
branches are much more abundant, but at the same time considerably 
smaller, than at the fourth month. Their stroma, which is made up of 
spindle-shaped cells, is denser, is occupied in great part by blood vessels, 
and differs markedly from the mucoid tissue of the earlier months. These 
changes have already been referred to, and are clearly shown in Fig. 138. 

The epithelium covering the villi has also undergone marked change; 
Langhans* layer has disappeared and there remains only a thin layer 
of syncytium, which gives rise to fewer buds than previously. In many 
villi immediately under the epithelium, and occupying the former posi¬ 
tion of Langhans* cells, a thicker or thinner layer of canalized fibrin 
may be observed. This was first described by Langhans, is of constant 
occurrence in the latter half of pregnancy, and is probably indicative 
of senility of the organ. At the same time, many of the arteries present 
all stages of an obliterating endarteritis, to which, in part, the forma¬ 
tion of the tissue in question should be attributed. 

The superficial portion of the decidua at this period is covered by 
canalized fibrin, which probably results from coagulation necrosis of 
the cell nodes and columns. In the deeper layers numerous giant cells 
are observed, which occasionally extend into the connective-tissue septa 
between the muscle fibers. They are of various shapes, and represent 
portions of trophoblast which have wandered down into the decidua. 

From the free surface of the decidua numerous elevations of vary¬ 
ing shape and size extend upward for a greater or less distance into the 
placenta—the so-called decidual septa. They are now known to rep¬ 
resent masses of trophoblast, which have not been converted into villi, 
and are composed of cuboidal or polygonal cells with round vesicular, 
deeply staining nuclei. Owing to the absence of blood vessels they are 
very prone to degenerative change and tend to become converted into 
canalized fibrin, or to lead to the formation of small cystic structures. 

The space- between the chorionic membrane and the free surface of 
the decidua serotina is designated as the 'placental space; into this the 
chorionic villi dip, thereby subdividing it into myriads of irregularly 
shaped cavities which communicate freely with one another—the inter¬ 
villous spaces. These are lined throughout by syncytium, except where 
it has given place to canalized fibrin. The syncytium is thinner than 
in the earlier months, and under suitable magnification its protoplasm 
presents a vacuolated appearance, which, according to Marchand, is due 
to the glycogen normally contained in it having been dissolved out by 

the fluids used in hardening the tissue. 

The intervillous spaces are at no time lined by endothelial cells, 
and it is probable that what has been described as such in reality rep¬ 
resents thinned-out syncytium. Hence, it would appear that the inter- 


40 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


villous spaces are lined entirely by foetal tissue, and that the maternal 
blood, which is circulating through them, lies outside of the body of 
the mother. The maternal blood gains access to the placental space by 
branches of the uterine arteries, which pursue a convoluted course 
through the decidua serotina and, after their walls have gradually 
become reduced to a single layer of endothelium, open upon the sides 
of the decidual septa. The blood escapes from the intervillous spaces 
through more or less funnel-shaped openings upon the surface of the 
decidua, which can be traced directly into large venous sinuses in its 
depths. Consequently, there must be a distinct circulation through the 
inter-communicating intervillous spaces, though it is necessarily more 
sluggish than elsewhere in the body. 

The nature of the intervillous spaces and the question as to whether 
they contain maternal blood have given rise to a great deal of discussion. 
Vater, Noortwyk, and William and John Hunter, in 1754, expressed an 
affirmative opinion; and the last two investigators conclusively demon¬ 
strated it by injection experiments. Similar results were obtained by 
E. H. Weber in 1842. But this work was gradually lost sight of, and 
all sorts of theories were evolved concerning their nature. Braxton 
Hicks, Ercolani, and others believed that they contained so-called uterine 
milk, which was secreted by the mucous membrane of the uterus. Such 
a statement is correct for the pig and cow, but is incorrect for woman, 
and clearly demonstrates the fallacy of drawing inferences from con¬ 
ditions observed in other species. Correct conceptions were finally 
established by the work of Farre, Turner, Waldeyer, Bumm, Leopold, 
and others, who showed conclusively that vessels of the mother could 
be traced into the intervillous spaces, which they supplied with maternal 
blood. This was especially well demonstrated by Waldeyer, who, in five 
pregnant cadavers, was able to inject the intervillous spaces from the 
maternal vessels. Furthermore, the study of early ova in situ has 
placed the question beyond all reasonable doubt. 

In view of these facts, then, the placenta must be regarded as a 
collection of maternal blood, included between the chorionic membrane 
and the decidua basalis, into which the villi dip and by which they are 
surrounded. Some idea of the complexity of its vascular arrangement 
may be gained from Plate YII, which represents a corrosion preparation 
of the foetal portion of a full-term placenta, which was injected through 
the umbilical arteries and veins with red and blue celloidin. 

Normally there is no communication between the foetal blood con¬ 
tained in the chorionic villi and the maternal blood in the intervillous 
spaces, and it would appear that the transmission of substances from 
one to the other is accomplished partly by osmosis and partly by the 
direct cellular activity of the chorionic epithelium, the process being 
analogous to that which takes place in the tubules of the kidney and 
other organs. The effete materials from the foetus are carried by the 
umtylical arteries to the capillaries of the terminal villi, whence they 
are transmitted to the maternal blood in the manner just described. 
At the same time the oxygen and the materials needed for the nutrition 
of the foetus are taken up from the former and carried bv the umbilical 


PLATE YTJ 



VESSELS. X H- 









THE AFTER-BIRTH 


147 


vein to the foetus. Thus, in a general way, we may say that the placenta 
represents the lungs, stomach, and excretory organs of the unborn child. 

Since the time of C. Bernard glycogen has been observed in various 
portions of the placenta—decidua, villi, chorionic membranes and am¬ 
nion. The researches of Flesch, Todyo and others show that it is most 
abundant during the first two months of pregnancy, but that traces 
can he discovered even at term. 

The Afterbirth. The placenta, as it is cast off from the uterus after 
the birth of the child, is a flattened, roundish, or oval organ—15 to 18 
centimeters in diameter, and 2 to 3 centimeters in height at its thickest 
pait fiom the margins of which the membranes extend. Ordinarily 
its weight is about 1/6 of that of the foetus, so that when the latter is 
normally developed the placenta weighs from 500 to 600 grams. 

It presents for examination two surfaces and a margin—the surface 
which was in contact with the decidua basalis being designated as the 
maternal or outer, and that directed toward the cavity of the ovum as 
the foetal or inner surface. The former is covered by a thin layer of 
decidua and presents a ragged, torn appearance, being divided by de¬ 
pressions of varying depth into a number of irregularly shaped areas, 
the so-called cotyledons, which vary considerably in number, as many 
as twenty being sometimes observed. On careful examination of the 
decidual surface, numerous vessels may lie seen which have been torn 
through when the placenta was separated. These were first observed 
by John Hunter, and Klein was able to count 51 arteries and 53 veins 
in a single specimen. 

The foetal or inner surface presents a glistening appearance, owing 
to the fact that it is covered by amnion, which, however, is only slightly 
adherent. When the latter is removed it leaves a coarsely granular 
surface, upon which the umbilical cord is usually inserted somewhat 
eccentrically, though it may be just at the center of the organ or near 
its margin. The various modes of insertion will be considered when we 
take up the abnormalities of the placenta. 

The vessels composing the umbilical cord spread out beneath the am¬ 
nion and rapidly divide, but the main branches remain upon the fcetal 
surface of the placenta until its margin is reached. In many instances 
a large vein, which is known as the circular sinus, extends around a 
considerable portion of the periphery of the placenta, but only rarely 
completely encircles it. 

The foetal membranes extend from the margins of the placenta, and 
consist of the amnion, chorion, and a thin layer of decidua. The amnion, 
the innermost of the membranes, is a thin, transparent, glistening 
structure, which is rarely thicker than a sheet of writing paper. Its 
outer surface is closely applied to the chorion, from which, however, it 
can usually he separated without difficulty. The chorion is more opaque 
and thicker than the amnion, though it rarely exceeds 1 millimeter in 
thickness. It represents the chorion laeve of the early months, and 
under the microscope is seen to possess a number of degenerated villi. 
Climrimr to its outer surface are a few shreds of decidual tissue, which 
are all that is cast off immediately after the birth of the child. Fig. 



Fig. 151.—Maternal Surface of Mature Placenta, showing Cotyledons; Mem¬ 
branes turned Back. X 












UMBILICAL CORD 


149 


153 represents a section through the foetal membranes and the uterine 
wall outside of the placental site, and gives a good idea of their com¬ 
position. 

Umbilical Cord.—The umbilical cord, or funis, extends from the navel 
of the child to the foetal surface of the placenta. Its exterior presents 
a dull white, moist appearance, and through it shimmer the umbilical 



±j?jlL£LlMA. jl * • L v- . ^ 


EL 

” - 

Fig. 153. —Fcetal Membranes and Uterine Wall. X 75. 

a., amnion; c.t., connective tissue of amnion and chorion; c.c., chorionic epithelium; c.f. 
canalized fibrin; d. t decidua; g., gland; m., muscularis; v., vein; V., atrophic villus. 


vessels—two arteries and a vein. It varies from 1 to 2.5 centimeters in 
diameter, and averages about 55 centimeters in length; though in ex¬ 
treme cases it may vary from 0.5 to 198 centimeters. The average 
length of 1,000 cords, which were measured at the Johns Hopkins 
Hospital, was 55 centimeters, the shortest being less than 1 and the 
longest 100 centimeters. 

The cord frequently presents a twisted appearance, the coiling 
usually being from left to right. As the vessels are usually longer 
than the cord, they are frequently folded upon themselves, thus giving 
rise to nodulations upon the surface which are designated as false knots. 









150 


MATURATION, 


FERTILIZATION AND 


DEVELOPMENT OF OVUM 




The cord is covered by a sheath of amnion which is closely adherent 
to it. Under the microscope, the covering epithelium usually consists 
of a single layer of flattened cells, although occasionally it is ananged 
in several layers resembling those of the skin. Except for the vessels, 


the interior of the cord 
is made up of a mu¬ 
coid connective - tissue 
—the so-called Whar- 
tonian jelly. 

On microscopic ex¬ 
amination of sections 
through any portion 
of the cord, one gen¬ 
erally finds near its 
center a small darkly 
area, which 


staining 


under higher magnifi- 


Fig. 154.— Epithelium of Umbilical Cord. X 110. 


cation appears as a 
small duct lined by a 

single layer of cuboidal or flattened epithelial cells, and surrounded 
by a zone of relatively dense connective-tissue. This is the duct or 
stalk of the umbilical vesicle. On the other hand, in sections taken 


just beyond the um¬ 
bilicus of the foetus, 
one occasionally finds 
a second duct, which 
represents the remnant 
of the allantois, but 
this is never found at 
the maternal end of 
the cord. 

Formerly it was 


taught that the cord 


was derived from the 
allantois, but the re¬ 
searches of His have 
definitely shown that 
such is not the case in 
man. In the youngest 
human ova, in which 
the embryo consists 
merely of a minute 
amnion and yolk sac. 
it is connected with 
the inner surface of 
the chorionic mem¬ 
brane by a thick mass of mesodennic or connective-tissue, which His 
designated as the abdominal pedicle or body stalk, and which, after 
increasing in length and receiving a covering of amnion, becomes con- 


Fig. 155.— Umbilical Cord, Fcetal End. X 5f<?. 

U.A., umbilical artery; U.S ., remnant of umbilical 
stalk; U.V., umbilical vein. 

















UMBILICAL VESICLE 


151 


, - -~ ^ ^ Duuvuui^ ucmg IcpiCStHIieU 

entodermal tubule at the foetal end of the abdominal pedicle, 
occasionally persists in the foetal end of the cord at the end of 



&> fe* • 

w . \ » «. 

.* Ik »** 



' 


VW!,. 


«' i 

«*>•• **» 

y rrU.S. 
•-=' > • » .. ** 1 

-* * t VI 

, a ' ci'i 

M* W u - ■ ■■* 

r * '» » i| 

# 4i 

• & • i 

& k .: £ 

*■ if.J.'i: . . ... 






Fig. 156. — Section 
Cord, showing Stalk 
Vesicle. X 110. 


through Umbilical 
of 


Umbilical 


verted into the umbilical cord. Furthermore, the allantois in man at 
no time develops into the imposing organ which it becomes in many 
animals, but always remains a rudimentary structure, being represented 
by an 
which occ; 
pregnancy. 

Fig. 157 represents a section through the abdominal pedicle of one 
of the early embryos studied by His, and clearly shows its analogy with 
the embryonic area. The great 
bulk of the structure is made ,, -' i9r ' ; ' J T " 
up of mesodermic tissue in 
which the umbilical vessels and 
the allantois are embedded; 
its dorsal surface is covered by 
a single layer of ectoderm, 
showing at its middle a slight 
depression which represents a 
continuation of the medullary 
groove, while arching over it is 
the amnion. In its further de¬ 
velopment the amnion, corres¬ 
ponding to the somatopleure, 
extends downward and inward, 
eventually inclosing a small 
portion of the coelom in a way 
similar to that in which the 

abdominal walls are formed in the embryo itself (Fig. 158). In this 
cavity the stalk of the umbilical vesicle or yolk sac is included. 

Fig. 159 represents a thirty days 7 embryo described by His, and gives 
a very good idea of the manner in which the stalk of the umbilical vesicle 

gradually becomes included within the 
cord. 

Umbilical Vesicle.—The yolk sac, or, 
as it becomes later, the umbilical vesicle, 
is a very prominent organ at the beginning 
of pregnancy, and is present in all early 
ova. In its earliest stages it represents the 
largest and most striking structure con¬ 
nected with the embryo, but as the latter 
develops, it becomes relatively smaller, and, 
as we have already shown, is taken up in 
great part to form the intestinal canal, so 
that after the formation of the abdominal 
walls it protrudes from the umbilicus into 
the ccelomic cavity as a rounded sac with a 
distinct stalk. As pregnancy advances the sac becomes smaller and its 
stalk longer. 

The structure persists throughout pregnancy, and can nearly always 
be found at full term, when it is represented by a flattened oval sac, 3 to 



Abdominal Pedicle of 2.25- 
Millimeter Embryo (His). 
X 50. 

AIL, allantois; M.G., medullary 
groove; U.A., umbilical ar¬ 
tery; U.V., umbilical vein. 














152 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


5 millimeters in diameter, which usually lies on the foetal surface of the 
placenta, between the chorion and amnion, but occasionally in the mem¬ 
branes just beyond the placental margin. It is connected with the um¬ 
bilical cord by a fine pedicle—the stalk, which, as has been already indi¬ 
cated, may be seen in sections through the cord at term. Schultze in 
1861 was able to demonstrate the umbilical vesicle in 146 out of 150 
mature placentae examined. Meyer has found that the vesicle may 
sometimes exceed the usual proportions, and measure as much as 10 to 
15 millimeters in diameter. 

The intra-abdominal portion of the duct of the umbilical vesicle, 
which extends from the umbilicus to the intestine, usually atrophies and 



Fig. 158. —Section through Young Um¬ 
bilical Cord (Minot). 

A., artery; All., allantois; U.S., stalk of 
umbilical vesicle; V., vein. 


Fig. 159. —Stalk of Umbilical Vesicle 

BEING INCLUDED IN THE UMBILICAL 

Cord (His). 


disappears, but occasionally it remains patent, forming what is known as 
Meckel’s diverticulum , which may play an important pathological part 
in later life. 

In animals whose ova possess a large amount of yolk, the umbilical 
vesicle is the main source of nutrition for the embryo; but in women its 
significance is not so clear, since the proportion of yolk is exceedingly 
small. In some of the lower animals it affords a means of vascularizing 
the chorion, while in still others it takes part in the formation of an 
accessory placenta, in addition to the main one which is vascularized 
from the allantois. It must, however, play an important part in the 
economy of the embryo, as it develops a considerable circulation, and, 
as Selenka has shown, forms numerous crypts from its entodermal 
lining. 








LITERATURE 


153 


LITERATURE 


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Ueber die Entwickelung des miitterliehen Blutkreislaufes in der menschl. Pla¬ 
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Duval. Le placenta des rongeurs, Paris, 1892. 

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Ercolani. Della struttura anat. della caduca uteiina, etc. Bologna, 1874. 

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yon Franque. Cervix und unteres Uterinsegment. Stuttgart, 1897. 
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Heine u. IIofbauer. Beitrag z. friihesten Eientwickelung. Zeitschr. 1. u. 

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TTerff. Beitrage zur Lehre von der Placenta und von den miitterliehen Eihullen. 

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Herzog. The Earliest Known Stages of Plaeentation, etc,, in Man. Am. J. 

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JIeukelom. Ueber die menschliche Plaeentation. Arch. f. Anat. u. 1 iivsiol., 


Anat. Abth., 1898, 1-36. 





154 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


Hicks. The Anatomy of the Human Placenta. Trans. London Obst. Soc., 1873, 
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His. Bauchstiel und Nabelstrang, Anatomic menschlicher Embryonen, 1885, iii, 
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Zu.r Histologie der Extrauterinschwangerschaft, nebst Bemerkungen iiber ein 
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Beobachtungen an jungen menschlichen Eicr. Anat. Hefte, 1902, 147. 








LITERATURE 


155 


Beitrage zur Kenntniss der normalen u. path. Histologie der Decidua. Archiv f 
Gyn., 1904, lxxii, 155-167. 

Merttens. Beitrage zur normalen u. path. Anatomie der menschlichen Placenta. 
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Meyer. On the Structure of the Human Umbilical Vesicle. Amer. J. Anat. 
1904, iii, 155-166. 

Miller. Das jiingste operativ erhaltene menschliche Ei. Berliner klin. Wochen- 
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Minot. Uterus and Embryo. Jour, of Morphology, 1889, ii, No. 3. 

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Ueber das jiingste bisher bekannte menschl. Abortivei. 1921, lxii, 352-405. 
Nitabuch. Beitrage zur Kenntniss der menschlichen Placenta. D. I., Bern, 1887. 
Noortwyk. Quoted from Waldeyer. 

Outerbridge. Decidual Beaction in the Appendix. Jour. Am. Med. Assn., 1913, 
lxi, 1702-1704. 

Overlach. Die pseudomenst. Mucosa uteri. D. I., Miinchen, 1885. 

Painter. The Spermatogenesis of Man. J. Exp. Zoology, 1923, xxxvii. 

Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. 

Rohr. Die Beziehungen der miitterlichen Gefasse zu den intervillosen Baumen 
der reifen Placenta, speciell zur Thrombose derselben (“woisser Infarct”). 
D. I., Bern, 1889. 

Buge. Ueber die menschliche Placenta. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 
550-588. 

Schick. Ueber die Lymphgefasse d. Uterusschleimhant wahrend der Schwanger- 
schaft. Archiv f. Gyn., 1905, lxxvii, 1-20. 

Sciilagenhaufer und Verocay. Ein angles menschliches Ei., Archiv f. Gyn., 1916, 
cv, 151-168. 

Schmorl. Ueber grosszellige (decidua-ahnliche) Wucherungen auf dem Peri¬ 
toneum u. den Ovarien bei intrauterine.r Schwangerschaft. Monatsschr. f. 
Geb. u. Gyn., 1897, v, 46. 

Schultze. Das Nabelaschen, ein constantes Gebilde in der Nachgeburt des aus- 
getragenen Kindes. Leipzig, 1861. 

Selenka. Keimblatter u. Primitivorgane der Mans. Studien iiber Entwickelungs- 
geschichte der Thiere, 1883, H. 1. 

Die Blatterumkehrung im Ei der Nagethiere, ditto, 1884, H. 3; 1891, H. 5. 
Menschen-Affen, Wiesbaden, 1899, ii; 1900, iii, Lieferung. 

Blattuinkehr im Ei der Affen. Biol. Zentralbl., 1898, xviii, 552-557. 

Sharkey. English translation of Midler’s Handbuch der Physiologic, according 
to Schroeder ’s Lehrbuch, XIII. Aufl., 1899. 

Sobotta. Die Befruclitung und Furchung des Eies der Maus. Archiv f. mikr. 
Anat., 1895, xlv, 15-93. 

Die Entwickelung des Eies der Maus. Archiv f. mikr. Anat., 1903, lxi, 274-330; 
and 1911, Ixxviii, 271-352. 

Spee. Beitrag z. Entwickelungsgeschichte der friiheren Stadien des Meerschwein- 
chens, etc. Archiv f. Anat. u. Phys., Anat. Abth., 1883, 44-60. 

Neue Beobachtungen iiber selir friihe Entwickelungsstufen des menschlichen 
Eies. Archiv f. Anat. u. Phys., Anat., Abth., 1896, 1-30. 

Beobachtungen an einer menschl. Keimscheibe mit offener Medullarrinne, etc. 

Archiv f. Anat. u. Phys., Anat. Abth., 1899, 159-176. 

Die Implantation des Meerschweinchensei in die TJteruswand. Zeitschr. f. 

Morphol. u. Anthropol., 1901, iii, 130-182. 

Demonstration eines junges Stadium der menschlichen Eieinbettung. Veih. d. 
deutschen Gesellsch. f. Gyn., 1906, xi, 421-422. 








156 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 


Strahl. Die Embryonalhiillen der Sauger und die Placenta. Hertwig’s Hand- 
buch des Entwickelungslehre, 1906, Bd. I, Theil II, 235-368. 

Streeter. A Human Embryo of the Presomite Period. Contributions to Em¬ 
bryology, No. 43, Washington, 1922. 

Thompson. The Maturation of the Human Ovum. .1. of Anat., 1919, Jiii, 172-208. 

Todyo. Ein junges menschl. Ei. Archiv f. Gyn., 1912, xcv, 425-460. 

Turner. Observations on the Structure of the Human Placenta. Jour. Anat. 
and Physiol., 1873, vii, 120; also 1877, xi. 

Unterberger. Exp. Untersuchungen uber ektopische Decidua. Monatschr. f. 
Geb. u. Gyn., 1921, li, 116-122. 

Van Beneden. Recherches sur les premieres stades du developpement du murin., 
Anat. Anzeiger, 1899, xvi, 305-334. 

Vater. Quoted from Waldeyer. 

Volk. Das Vorkommen on Decidua in der Cervix. Archiv f. Gyn., 1903, lxix, 
681-687. 

Waldeyer. Bemerkungen iiber den Ban der Mensehen- und Atfen-placenta. Archiv 
f. mikr. Anat., 1890, xxxv, 1-52. 

Weber. Zusatze vom Ban und den Verrichtungen der Geschlechtsorgane. Abh. 
der kgl. sachsischen Akademie, 1846. 

Webster. The Changes in the Uterine Mucosa during Pregnancy and in the 
Attached Foetal Structures. Amer. Gyn. and Obst. Journal, 1897, x, 168-264 
and 535-662. 

Human Placentation. Chicago, 1901. # 

von Weiss. Zur Kasuistik der Placenta praevia centralis. Centralbl. f. Gyn., 
1897, 641-649. 

Williams. Decidual Formation throughout the Uterine Muscular is. Trans. 
Southern Surg. and Gyn. Assn., 1905, xvii, 119-132. 

Winckler. Textur, Structur und Zellleben in den Adnexen des menschlichen 
Eies. Jena, 1870. 





CHAPTER Y 


THE FCETUS 

The Foetus in the Various Months of Pregnancy.—It is important 
that the physician be able to tell approximately the age of embryos and 
prematurely born children, and we shall therefore give a short descrip¬ 
tion of the foetus at its various periods of development. 

The actual duration of pregnancy is not yet known, but ordinarily 
two hundred and eighty days, or ten lunar months, elapse between the 
commencement of the last menstrual flow and the onset of labor, though 
a considerable number of children are born shortly before or after the 
expiration of that period. 

The following details concerning the development of the unborn 
child are taken in great part from His, who distinguished three periods 
in its evolution. Thus, during the first two weeks of pregnancy the 
product of conception is designated as the ovum; from the third to the 
fifth week—the period during which the various organs are developed 



Fig. 160. Fig. 161. Fig. 162. Fig. 163. Fig. 164. Fig. 165. 


Figs. 160-165.— Early Embryos described by His. 

and a definite form is assumed—it is known as the embrvo; after the 
fifth week it becomes the foetus. 

First Two W eelcs .—The earliest human ova with which we are ac¬ 
quainted were enumerated in the preceding chapter. With the exception 
of the one described by Bryce and Teacher, these were vesicular struc¬ 
tures whose main feature was the chorion, to one side of whose in¬ 
terior was attached the future emhrvo, so small a body that its component 
parts could be distinguished only with the aid of the microscope. In 
each instance the embryonic area was covered by a well-developed 
amnion, and the great bulk of the embryo consisted of the yolk sac. 
Moellendorfs ovum presented the earliest stages in the formation of the 
emhryo itself—namely, the primitive streak. Figs. 160 to 165 represent 
early ova described by His. 

Third Week .—The embryonal period begins with the third week, in 
the latter part of which can be detected the beginning formation of the 
medullary groove and canal, soon to he followed by the appearance of the 
head folds. At this stage of development the abdominal pedicle is seen 
coming off from the tail end of the embryo, and lying almost in the same 
axis with it. The embryo is concave on its dorsal surface, and is made 
up in great part of the yolk sac. 


157 






158 


THE FCETUS 


A little later the formation of the double heart may be noted; while 
the cerebral and optic vesicle, soon appear, as well as the visceral ai dies 
and clefts. The yolk sac becomes more and more constricted, and is 
connected with the ventral surface of the embryo by a broad pedicle. 
At the very end of the third week (about the twenty-first day) the 
limbs make their appearance as small buds upon the surface of the 
embryo. 

Fourth Week .—'This week is characterized by a great increase in the 
size of the embryo, which becomes markedly flexed upon its ventral sur¬ 
face, so that its head and tail ends come almost in contact. The rudi¬ 
ments of the eyes, ears, and nose now make their appearance, and the 



Fig. 1G6. Fig. 167. Fig. 168. Fig. 169. 

Figs. 166-169. —Embryos from Fourth and Fifth Weeks (His). X 2. 


umbilical vesicle becomes still more pedunculated. At the end of the 
first lunar month the embryo measures from 7.5 to 10 millimeters (0.3 
to 0.4 inch) in length. 

Second Month .—In the first half of the second month the human 
embryo does not differ essentially in appearance from that of other mam¬ 
mals. It is still markedly bent on itself, and the visceral clefts and 
arches are the most prominent characteristics of its cephalic region, 
while the extremities are in a rudimentary condition. In the latter 
part of the month, owing to the development of the brain, the head 
becomes disproportionately large, and assumes a certain resemblance to 
that of a human being. At the same time the nose, mouth, and ears 
become relatively less prominent and the extremities more developed, 
so that it can be seen that each is made up of three portions. The 
external genitalia also make their appearance in the latter part of this 
month, and at its end the foetus has attained a length of 2.5 centimeters 
(1 inch). 

Third Month .—At the end of this month the entire product of con¬ 
ception is about as large as a goose’s egg, and the embryo measures from 
7 to 9 centimeters in length. Centers of ossification have appeared in 
most of the bones; the fingers and toes become differentiated and are 
supplied with nails; the external genitalia are beginning to show definite 
signs of sex. A foetus born at this time may make spontaneous move¬ 
ments if still within the amniotic sac or if immersed in warm saline 
solution. 

Fourth Month .—By the end of the fourth month the foetus is from 























159 



Fig. 170. Fig. 171. Fig. 172. 

Figs. 170-172. —Embryos from Second Month (His.). X 2. 


THE FCETUS IN THE VARIOUS MONTHS OF PREGNANCY 


10 to 17 centimeters long, and weighs about 120 grams. Casual ex¬ 
amination of the external genital organs will now definitely reveal the 
sex. 

Fi fth Month .—The foetus varies from 18 to 27 centimeters in length, 
and weighs about -80 grams. Its skin has become less transparent, a 
downy covering is seen over its entire body, while a certain amount of 
typical hair has made its appearance on the head. 

Sixth Month. At the end of the sixth month the foetus varies from 
28 to 34 centimeters in length, and weighs about 634 grams. The skin 
presents a markedly w r rinkled appearance, 
and fat begins to be deposited beneath it; 
the head is still comparatively quite large. 

A foetus born at this period will attempt 
to breathe, but always perishes within a 
short time. 


Seventh Month .—The length during this month varies from 35 to 
38 centimeters, and the foetus attains a weight of over 1,200 grams. The 
entire body is very thin, the skin is reddish and covered with vernix 
caseosa. The pupillary membrane has just disappeared from the eyes. 
A foetus born at this period moves its limbs cpiite energetically and cries 
with a weak voice; but, as a rule, it cannot be raised, even with the most 
expert care, although a success is occasionally recorded. 

It is generally believed among the laity that a child born at the end 
of the seventh month has a better chance of living than v'hen it comes 
into the world four weeks later. This idea is a remnant of the old 
Hippocratic doctrine and is altogether erroneous, as the more developed 
the child the greater are its chances for life. 

Eighth Month .—At the end of the eighth month the foetus has at¬ 
tained a length of 42.5 centimeters, and a weight of about 1,900 grams. 
The surface of the skin is still red and wrinkled and the child resembles 
an old man in appearance. Children born at this period may live if 
properly cared for, though their chances are not very promising. 

















160 


THE FOETUS 


Ninth Month .—At the end of the ninth month the foetus is 46 cen¬ 
timeters long, and weighs about 2,500 grams. Owing to the deposition 
of subcutaneous fat, the body has become more rotund and the face has 
lost its previous wrinkled appearance. Children born during this month 
have a very good chance of life if properly cared for. 

Tenth Month .—Full term is reached at the end of this month. The 
foetus is now fully developed, and presents the appearances which we 
shall consider in detail when the new-born child is described. 

The foetus grows relatively much faster in the early than in the later 
months of pregnancy. According to Jackson, the weight of the mature 
ovum is only 0.000004 gram, which increases to 0.04 gram by the end 
of the first month after fertilization—an increase of 9,999 times, or 
practically one million per cent. In the second and third months the 
rate of increase has become reduced to 74 and 11 times respectively, and 
gradually falls to 0.3 times in the last month. Even this comparatively 
slow rate is not maintained after birth, for if it were the child would 
weigh about 160 pounds by the time it was one year old. 

Owing to inequalities in the length of the legs, and the difficulty of 
maintaining them in extension during mensuration, the determination of 
the sitting height (crown-rump) is more accurate than that of the stand¬ 
ing height. According to Streeter, the average sitting height and weight 
of the foetus at the end of the various lunar months, as determined from 
704 specimens, are as follows: 


LUNAR XIONTH. 

SITTING HEIGHT. 

WEIGHT. 

2nd. 

0.23 centimeter 

1.1 grams 

14 2 “ 

3rd. 

6.1 

centimeters 

4th. 

11.6 

( ( 

108 0 “ 

5th. 

16.4 

i < 

316 0 “ 

6th. 

20.8 

i i 

630.0 “ 

1,045.0 “ 

1,680.0 “ 

2,478.0 “ 

3,405.0 “ 

7th. 

24.7 

l i 

8th. 

28.3 

i < 

9th. 

32.1 

i < 

10th. 

36.2 

l ( 




Such figures possess only an approximate value, and generally speak¬ 
ing the length affords a more accurate criterion of the age of a child than 
its weight. Haase has suggested that the length of the embryo in centi¬ 
meters may be roughly approximated during the first five months by 
squaring the number of the month to which the pregnancy has advanced; 
in the second half of pregnancy, by multiplying the month by 5, as is 
shown in the following table: 


At the end of the first month. . . 
11 “ “ second month. 

“ “ “ third month. . 

‘ ‘ ‘ 1 ‘ 1 fourth month. 

11 11 “ fifth month. . . 

“ ‘ ‘ ‘ ‘ sixth month. . 

11 11 11 seventh month 

‘ * 11 11 eighth month. 

“ “ “ ninth month. . 

“ “ “ tenth month. . 


1X1, 1 centimeter. 

2X2, 4 centimeters. 

3X3, 9 

4X4, 16 

5X5, 25 
6X5, 30 
7X5, 35 
8X5, 40 
9X5, 45 “ 

10X5, 50 






























THE FOETUS IN THE VARIOUS MONTHS OF PREGNANCY 161 


The Child at Full Term .—The average child at full term is 50 centi¬ 
meters or 20 inches long (36 centimeters or 14 inches sitting height), 
and weighs 3,250 grams or 1^4 pounds. The skin is smooth and polished 
in appearance, and shows no lanugo, except occasionally about the 
shoulders. Over the entire surface is spread a whitish, greasy material, 
the vernix caseosa, which is a mixture of epithelial cells, lanugo hairs, 
and the secretion of the sebaceous glands. The head is usually covered 
by darkish hairs 2 to 3 centimeters in length, and the cartilages of 
the nose and ears are well developed. The fingers and toes possess well- 
developed nails, which project beyond their tips. In male children 
the testicles are usually found within the scrotum; in girls the labia 
majora are well developed and are in contact with one another, and 
usually conceal the rest of the genitalia. The bones of the head are 
well ossified, and are in close contact at the various sutures. The eyes 
possess a uniformly slate color, so that it is impossible to predict their 
final tone. 

Blecard in 1828 described a center of ossification, 0.5 centimeter in 
diameter, in the lower epiphysis of the femur. He considered it a diag¬ 
nostic sign of maturity, but it is not infallible. Ballantyne and Browne 
found it of this size in only one-third of one hundred full term children. 
Adair and Scammon have likewise studied the ossification centers at 
birth by means of Rontgen rays and have found that the results are not 
constant, which is in accord with my observations. Ordinarily, the 
proximal epiphyseal center of the tibia and two centers in the tarsus are 
present at term, while all are lacking in the carpus. On the other 
hand, the first was lacking in 19 per cent, of their cases; in the tarsus, 
a third center, that of the cuboid, is sometimes added; while two centers 
were noted in the carpus of 15 per cent, of their infants. Such observa¬ 
tions invalidate the conclusions of Hahn, according to which absence of 
the proximal epiphyseal center of the tibia always indicates prematurity. 

My own experience is that while X-ray examination of the ossifica¬ 
tion centers gives important information, it cannot always be relied upon 
to determine whether the child is premature, mature or post-mature. 
For example, Ballantyne and Browne pointed out that a third tarsal 
center was never observed in the premature child, was present in ? out 
of 22 full term children, and yet was lacking in many which were clearly 
postmature. Holzbach holds that the most valuable sign oi maturity is io 
be found in the relation between the fronto-occipital circumference of 
the head and that of the shoulder, as in only 1 out of the 31 premature 
children which he examined did the latter equal the former in size. 
No one of these conditions affords indisputable proof of the maturity 
of a child, but when the majority of them are present the evidence be¬ 
comes fairly convincing. 

Negro babies at birth differ somewhat in appearance from white chil¬ 
dren, hut not so markedly as one might expect. Their skin presents a 
dusky, bluish-red hue, but does not at all suggest the darker color which 
it will assume in the course of a few weeks. Where there is a consider¬ 
able admixture of white blood, the dusky hue may he entirely absent, and 
the only certain evidence of negro ancestry will he found in an in- 


1G2 


THE FCETUS 


creased pigmentation about the 'external genitalia, and at the matrix 
of the nails. 

Weight of the New-born.—The average infant at birth weighs about 
3,250 grams (7% pounds), boys being usually 100 grams (3 ounces) 
heavier than girls. Marked variations are frequently observed, which 
are dependent upon the race and size of the parents, the number of chil¬ 
dren which the mother has borne, her mode of life, and her nutrition and 
general condition during the later months of pregnancy. In 707 full- 
term white children born at the Johns Ilopkins Hospital, T. F. Riggs 
found that the average length was 49.64 centimeters, and the average 
weight 3,316.9 grams (7.32 pounds), the smallest child weighing 2,180 
grams (4 pounds 12 ounces) and the largest 4,553 grams (10 pounds). 

Colored children weigh considerably less than white, a fact which, 
in large cities at least, is indicative of the physical degeneration which 
characterizes the race. Four hundred and seventy full-term colored 
children studied by Riggs averaged 48.75 centimeters in length and 
3,104.8 grams in weight, a difference of 211 grams (7 ounces) in favor 
of the white race. 

Perfectly healthy full-term children may vary from 2,300 to 5,000 
grams (5 to 11 pounds) in weight. They rarely exceed the latter 
figure, although one occasionally hears of children weighing 15, 16, and 
even 20 pounds at birth. The majority of such cases, however, must be 
regarded as apocryphal, and careful inquiry will usually show that the 
weight has been only roughly estimated by lifting the child in the hand, 
and was not based upon accurate determination. Winckel found only 5 
children that weighed over 5,000 grams in 30,500 deliveries, and Starcke 
16 in 34,000 deliveries in Leopold’s clinic. According to Ludwig, out 
of 15,166 children born in Chrobak’s clinic in Vienna, only 1 weighed 
5,300 grams (11% pounds), and Varnier stated that in seven years, 
at the Baudelocque Clinic in Paris, there were only 6 children that ex¬ 
ceeded 5,000 grams at birth, the heaviest weighing 6,150 grams (13 
pounds 9 ounces). Moreover, it is probable in many instances that the 
excessive weight of such children should be attributed to the fact that 
the pregnancy had persisted several weeks beyond the usual term—in 
other words, that they were post-mature. 

In some 25,000 children delivered under my supervision, the largest 
weighed 6,470 grams (14% pounds), and measured 62.5 cm. in length. 
Dubois, in 1897, collected from the literature 28 cases in which the child 
weighed 5,600 grams (12 pounds) or more at birth, and stated that the 
heaviest children on record were reported by Ortega, Rachel and Neumer, 
and Beech, and weighed respectively 11,300, 11,250, and-10,750 grams. 
Ludwig, in 1896, reported that he had been obliged to perform cesarean 
section, after craniotomy and amputation of the extremities, in order to 
deliver a child weighing 7,700 grams (16 pounds 10 ounces). In spite 
of these exceptional cases, one should be extremely skeptical in accept¬ 
ing reports concerning phenomenally heavy children, unless convinced 
that the reporter is a truthful person and has weighed the child upon 
an accurate balance. 

On the other hand, healthy full-term children frequently weigh less 


WEIGHT OF THE NEW-BORN 


163 


than 3,250 grams, and sometimes as little as 2,300 grams (5 pounds) ; 
although, when the weight falls below 2,500 grams, the child should be 
considered as premature unless its length exceeds 45 cm. Any weight 
below this limit, in the case of an infant born at term, should always 
lead one to suspect some disease on the part of the mother or foetus, as 
nephritis or syphilis. 

Generally speaking, premature children weighing less than 1,500 
grams and measuring less than 35 cm. in length have practically no 
chance of life, though in exceptional cases they may do well. Piering 
! reports raising a premature child that weighed only 1,120 grams at 
birth, and mentions instances in which children weighing only 717, 719, 
and 750 grams respectively were successfully reared. Dr. H. A. Powell, 
of Cleveland, informed me that he had successfully raised an infant 
which weighed 750 grams at birth. 

The size of the foetus usually increases with the age of the mother 
up to the thirtieth year, if pregnancies have not followed in too rapid 
succession. The size is also dependent, to a considerable extent, upon 
that of the parents, especially the father; and in many instances 
the child’s head closely resembles that of the latter in shape. 

The social condition of the mother and the comforts by which she is 
surrounded also exert a marked influence upon the child’s weight, heavier 
children being more common in the upper walks of life. Thus, on look¬ 
ing over the records of my private cases, I found that healthy full-term 
children averaged 3,795 grams in weight, as compared with 3,316.9 and 
3,104.8 grams for the white and colored children in hospital practice— 
a difference of 478 and 690 grams, respectively. 

Pinard and Bachimont, from a study of 4,445 cases observed in the 
Baudelocque Clinic, arrived at somewhat similar conclusions. They 
found that the children of women who had lived in the hospital for 
three months prior to confinement averaged 500 grams heavier than 
those of patients who had entered it just before or during labor. They 
consider that this difference is due to the better nourishment of the 
former class of patients, as well as to the avoidance of premature laboi 
incident to hard work. T. F. Riggs made similar observations in my 
service at the Johns Hopkins Hospital, but found that theie was a 
greater increase in weight in the colored than in the white children. 
He was inclined to attribute the difference to the fact that the hospital 
fare was no better than that which the white women received in their 
homes, but was superior to that to which the average colored woman is 

accustomed 

It is generally believed that the comparatively difficult labors of the 
women of the upper classes are due to the enervating influences of civ¬ 
ilization and luxury, while the easy labors of negroes are considered 
as manifestations of a closer approach to Nature. Such conclusions 
are not justified hy my experience, as the physical degeneration of colored 
women living in large cities is proven by the fact that in them the 
incidence of contracted pelvis is four or five times as great as in white 
women. Were this not counterbalanced by the lesser weight of the 
black children, and particularly by the smaller size and greater com- 














164 


THE FCETUS 


pressibility of their heads, labor would be a disastrous function, and 
would comparatively soon lead to a solution of the race problem. If 
the negro children were as large and had as hard heads as in the upper 
classes, I should be obliged to perform a cesarean section a week, instead 
of 15 or 20 each year, as at present. Accordingly, it appears permissible 
to attribute the more difficult labors in the upper classes to the larger 
size of their children, resulting from abundant nutrition and a life of 
ease, rather than to the enervating influences of civilization. 

Provided the pelvis is normal, it is unusual for children weighing 
less than 5,000 grams (11 pounds) to cause difficult labor simply from 
their size, since Yarnier has shown that the diameters of the head to 
not increase in the same ratio as the weight of the child. 

The Head of the Child.—From an obstetrical point of view the head 
of the child is its most important part, as the essential feature of labor 



Fig. 173.— Child’s Head at Term. X (American Text-Book.) 


is a process of adaptation between it and the various portions of the 
pelvic canal through which it passes. An accurate knowledge of its 
characteristics and size is therefore of capital importance. 

Only a comparatively small part of the head of the child at term is 
represented by the face, the rest being composed of the firm, hard skull, 
which is made up of two frontal, two parietal, two temporal bones, the 
upper portion of the occipital, and the wings of the sphenoid. These 
bony portions are not firmly united together, but are separated from one 
another by spaces filled with membrane—the sutures. Of these the most 
important are the frontal, between the two frontal bones; the sagittal, 
between the two parietal bones; the coronal, between the frontal and 
parietal bones; and the lamhcloid suture, between the posterior margins 
of the parietal bones and the upper margin of the occipital bone. All 
of these sutures can be felt during labor; whereas the temporal suture, 
which is situated on either side between the inferior margin of the 














THE HEAD OF THE CHILD 


165 


parietal and the upper margin of the temporal bones, is covered bv soft 
parts and cannot be felt on the living child. 

Where several sutures meet together an irregular space is formed 
which is closed by a membrane and designated as a fontanelle. Four 
such structures are usually distinguished: the greater and lesser, and 
the two temporal fontanelles. The greater or anterior fontanelle is a 
lozenge-shaped space situated at the junction of the sagittal and the 
coronal sutures. The lesser or posterior fontanelle is represented by a 
small triangular area at the intersection of the sagittal and lambdoid 



Occiput 


Bipar fetal 


Bitempordl 


sutures. These are readily felt 
during labor, and their recogni¬ 
tion gives important informa¬ 
tion concerning the position and 
presentation of the child. The 
temporal or gasserian fon- 



Fic. 174. —Child’s Head at Term. X 
(American Text-Book.) 


Fig. 175. —Head at Term, showin- 
Small, Sagittal, and Large Fong 
TANELLES. X 


tanelles, which are situated at the junction of the lambdoid and temporal 
sutures, cannot be felt on vaginal examination. 

Arnold Lea directed attention to the occasional presence of what ho 
designated as the sagittal fontanelle, which is a lozenge-shaped space 
found in the sagittal suture at a point about half-way between the 
greater and lesser fontanelles. He considers that it results from faulty 
ossification of the parietal bones, and states that it occurred in 4.4 per 
cent, of 500 fcetal skulls which he examined. I have met with it less 
frequently, and while T cannot adduce accurate statistics, I would esti¬ 
mate its incidence at about one per cent. In several instances its 
presence gave rise to a serious error in diagnosis. 

To aid us in forming definite ideas concerning the shape and size of 
the foetal head, it is customary to measure certain diameters and circum¬ 
ferences. The diameters most frequently used are: (1) the fronto- 









THE F(ETUS 


100 


occipital, which follows a line exlending from flic root of Ihc nose lo 
flu' most prominent portion of ilie occipital bone; (2) 1 hi* bipariefal, 
which represents the greatest transverse diameter ot tlu' head, and ex¬ 
tends from one parietal boss to the other; (3) tlie bitemporal, which 
represents the greatest distance between the two temporal sutures; ( I) 
the mento-occipital, from thi* chin to th(* most prominent portion ol tin? 
occiput; and ( >) the suboccipito-bregmatic, which lollows a line drawn 
from the middle of th(‘ large fontanelle to the under surface of’the 
occipital hone, just where it joins the neck. For convenience the vari¬ 
ous diameters are frequently designated by initials, which, with their 
several average' measurements, are given in tin* following table: 



I nitials. 

Average 

Length. 

Riggs’ Figures. 

Fronto-oceipital. 

F. (). 

11.75 cm. 

W liite. 
11.71 cm. 

Hlaok. 

11 . 20 cm. 

Biparietal. 

B. P. 

9.25 “ 

9.25 “ 

9.05 “ 

Bitemporal. 

B. T. 

8 

8 

7.SI “ 

Mento-occipital. 

M. (). 

13.5 “ 

13.33 “ 

13.31 “ 

Suboccipit o-bregmat ic. 

S. (). B. 

9.5 “ 

9.70 “ 

9.29 “ 


The greatest circumference of the head, which corresponds to the 
plane of the fronto-oceipital diameter, is 34.5 centimeters, while the least 
circumference, corresponding to the plane of the suboccipito-bregmatic 
diameter, is 32 centimeters. The figures just given are based upon the 
average measurements of a large number of heads just after birth, in¬ 
dividual variations being frequently encountered. As a rule, boys have 
somewhat larger heads than girls, and the children of nmltiparae than 
those of primiparae. As indicated in the table, Higgs's figures show 
that all of the diameters are shorter in negro children ; but such meas¬ 
urements give no idea of the greater softness and compressibility of their 
heads. According to Calkins the various measurements of the head 
bear a constant relation to the standing height of the child. Conse¬ 
quently, he states that measurements of the head, when plotted as ordi¬ 
nates against the standing height as abscissae, result in a straight line 
curve. This being the case, the relationship between anv two dimensions 
can he expressed by the straight line empirical formula— y — a x ±h; 
x and ?/ being body dimensions and a and h constants. 

A certain amount of motility exists at the sutures between the various 
bones composing the skull. This may vary within relatively wide limits f 
in different individuals, so that heads which afford the same diameters 
on actual measurement frequently differ markedly in the obstacle which 
they offer to labor: as the bones of one may be soft, compressible, and 
readily displaced, while those of another are firmly and densely ossified 
and admit of but little motility, the former being readily molded to 
the pelvic canal, while the latter are incapable of reduction in size. 

Physiology of the Foetus.—Our knowledge concerning the phvsiology 
of the foetus has been markedly enriched during recent years; neverthe¬ 
less, when compared with that of the adult, it offers many points con¬ 
cerning which we are but slightly informed or profoundly ignorant. 






















PHYSIOLOGY Of THK FKTI 


167 


Nutrition of the Fretus, —Owing to the Final] amount of yolk con¬ 
tained in the human ovum, the growth of the fcetus is almost entirelv 
dependent upon the amount of nutritive material which it obtain- from 
its mother. 

Jturirjg the first few months of pregnancy, a- Fehling first pointed 
out, the embryo consists almost entirely of water, and it i- d aring th- 
period that it grow- most rapidly. In the later month- of pregnane u 
when more solids are feeing added, the increase in size become? grad ram 
slower. Fehling’s conclusions mere confirmed bv Michel, no analvzec 
the feetus at various periods v.ith the result- noted in the following 
table, which indicates that, a- the fret - increase- in age. it con*aii - 
relatively less water and a markedly increased quantity of albuminoid 
materials, salts, and fat-. 


Water. 

A Jo jnuxiotd* 

Bah*. 

Fata. 

At 2\ months: 

93 %2 per cent 

4 49 per cent 

Trace. 

Trace. 

3d to 4th month 

89 9$ 

7 05 

1 729 per cent 

0379 per cent. 

7th month. 

$4.75 

10 04 “ 

_ 187 

1 $23 

At term. 

69.16 

13 96 “ 

3 373 

11.75 


For the first few days after the implantation of the ovum, its nutri¬ 
tion must be derived from the serum vhich accompanies the edematous 
condition of the decidua. Furthermore, trie -urro nding maternal t.-- ;e 
which has undergone necrosi- a- the re-ult of the dige-tive action of ‘he 
trophoblast, a- well a- the greatly a ugmerred gland dar secretion which 
character]'zes this period, probably serve- a- & pa m;rn. to which is added 
the glycogen, which Dries sen ha- shown accumulates in the glandular 
epithelium and the stroma of the endometrium during the period of 
premenstrual swelling. Within the next week intervillous spaces, which 
are filled with maternal blood. begin to develop between tine trophoblast 
and decidua. As the chorionic villi a* thi- period are devoid of vessels, 
the only way in which nutritive material, which has been taken up ny 
the trophoblast from the maternal blood, can be transmitted to the 
embryo is by means of direct osmosis. 

In the third week of pregnancy the omrdialome-enteric vessels main 
their appearance upon the surface of ‘he umbilical ve-iele. an u na‘ - m 
nutritive materials the latter may contain are corn . to the embryo by 
them. During the fourth week branches of the umbilical ^--e.s appear 
in the chorionic villi, and from that time on make possible me direct 
transmission of nutritive material from the maternal m the feeta. blood. 

FAe F^f<z7 Circulation. —Owing to the fact that the lungs do not 
function, and that the materials needed for the nutrition of the rums 
are brought to it from r he placenta by me umbilical w-dn. the foetal 
circulation differs materially from ‘hat of the adult Ra‘e • III )• The 
blood is purified and laden with nutritive material in the placenta, and 
is then carried to the frntus through the umbilical vein, which, arm 
perorating the abdominal wall, divides into two branches. Oi these ne 
smaller unites with the portal vein, the blood from which circulates 











168 


THE FCETUS 


through the liver and then gains access to the inferior vena cava through 
the hepatic vein. The other larger branch, which is designated as the 
ductus venosus, empties directly into the vena cava.> The contents of 
the vena cava above the hepatic vein, therefore, consist of a mixture of 
arterial blood from the placenta and venous blood returning from the 
lower extremities of the foetus. Thus far all investigators agree, but 
there is still considerable divergence of opinion as to the course the 
blood takes after leaving the vena cava. It is generally taught that upon 
entering the right auricle it is deflected by the intervention of the 
eustachian valve in such a manner as to pass through the foramen ovale 
into the left auricle, whence it passes into the left ventricle, which forces 
it into the aorta. On the other hand, the blood returning from the head 
and upper extremities by way of the superior vena cava is poured into 
fhe right auricle, and, crossing the current from the inferior vena cava, 
passes into the right ventricle, whence it is forced into the pulmonary 
arteries. But so long as the lungs do not function, only a small portion 
of this blood gains access to them, the greater part of it passing through 
the ductus arteriosus to the arch of the aorta, and being then carried 
to the rest of the body of the embryo. 

According to this view, the blood from the inferior and superior vena 
cava does not mix in the right auricle, but the two currents cross one 
another in such a way that the purer blood from the inferior cava 
passes directly to the left side of the heart through the foramen ovale, 
and is supplied in great part to the head and neck; while the less pure 
blood from the superior cava passes through the right auriculoventricular 
opening and is forced by the right ventricle into the pulmonary arteries 
and the ductus arteriosus. 

Pohlman (1909) states that this view is incorrect, as it is physically 
impossible for the two currents to cross one another without mixing. 
Accordingly, he believes that the two currents mix in the right auricle, 
while enough of the mixed blood passes into the left auricle through the 
foramen ovale to make up for the deficient return through the pulmonary 
veins. Ziegenspeck likewise believes that the blood in the two auricles 
is identical in composition, but that the result is accomplished in a 
different manner. 

In any event, the blood which has gained access to the aorta directly 
from the left, as well as from the right, ventricle through the ductus 
arteriosus is propelled down the aorta and given off to the various organs 
according to their needs; but the bulk of it enters the internal iliac and 
hypogastric arteries-—the latter after passing the umbilicus being desig¬ 
nated as the umbilical arteries—and through them gains access to the 
placenta. 

From the foregoing description it is apparent that the blood circu¬ 
lating in the foetus is at no time strictly arterial or strictly venous, but 
that the content of the inferior vena cava is purer than that of the aorta. 

The distinctive features of the foetal circulation are connected with 
the ductus venosus and arteriosus, the foramen ovale, the hypogastric 
arteries, and the umbilical cord. After birth these structures undergo 
marked changes. As soon as the child is born and begins to breathe, the 


PLATE VIII. 



FCETAL CIRCULATION 









PHYSIOLOGY OF THE F(ETUS 


169 


pulmonary circulation becomes established. As a result, a much greater 
quantity of blood is pumped by the right ventricle into the pulmonary 
arteries, while a lessened amount passes through the ductus arteriosus. 
Moreover, as soon as the circulation in the cord is abolished, the umbilical 
vein becomes functionless, and a diminished quantity of blood is returned 
to the right auricle by the inferior vena cava. This change leads to a 
diminution in the tension in the right auricle, while that in the left side 
of the heart is increased, bringing about the closure of the valvelike fora¬ 
men ovale. 

As the circulation through the umbilical arteries ceases almost imme¬ 
diately after the pulmonary circulation is established, the function of the 
hypogastric arteries is in abeyance, and their distal ends rapidly un¬ 
dergo atrophy and obliteration, which is usually complete three or four 
days after birth. The ductus venosus and umbilical veins also become 
occluded during the first week, whereas the closure of the ductus ar¬ 
teriosus is more gradual, and frequently its opening does not become 
impervious until several weeks after birth. Permanent closure of the 
foramen ovale does not occur for some time, and not rarely months elapse 
before it is completed. Occasionally it remains patent, and circulatory 
disturbances of greater or less gravity result from its persistence. 

Transmission of Substances through the Placenta .—As was shown 
when considering the structure of the placenta, there is no direct com¬ 
munication between the vessels of the chorionic villi and the intervillous 
blood spaces. In the first half of pregnancy foetal and maternal blood 
are separated from one another by the syncytium, Langhans’ layer of 
cells, a thicker or thinner leaflet of the stroma of the villus, and the 
walls of the foetal capillaries, while in the second half Langhans' layer 
gradually disappears. 

The independence of the two circulations is readily demonstrated 
during the first months of pregnancy by comparing the contents of the 
foetal vessels with that of the intervillous spaces. In the former large 
numbers of nucleated red corpuscles are found, which are never present 
in the latter. In order that substances may pass from the mother to the 
foetus, or in the reverse direction, it is necessary for them to traverse 
the layers of tissue which we have just mentioned. It would appear 
that gases and substances in solution pass by osmosis directly from the 
maternal to the foetal blood and vice versa, but that colloids and formed 
substances must undergo certain changes in the chorionic epithelium 
before they can be transmitted. 

The transmission of gaseous substances has been definitely demon¬ 
strated both by clinical observation and experimental work. Comparison 
of the blood in the umbilical vein and arteries, respectively, shows that 
the former is lighter in color, indicating that it is richer in oxygen than 
the latter. This fact has also been demonstrated experimentally by Zwei- 
fel, who showed that the blood in the umbilical vein, when examined by 
means of the spectroscope, contained oxyhemoglobin. Again, Cohnstein 
and Zuntz have demonstrated that the blood of the umbilical ^ein in tie 
sheep is richer in oxygen and poorer in carbon dioxid than that contained 
in the umbilical arteries. Zweifel has also shown that chlorofoim admin- 



170 


THE FOETUS 


istered to the mother is rapidly transmitted to the foetus, and Nicloux 
has made similar observations with ether. 

The increase in the size of the foetus affords conclusive evidence that 
nutritive and other materials must pass from the maternal to the foetal 
circulation, and this has been demonstrated experimentally for many 
substances in solution. The first work of this character we owe to 
Mayer, who in 1817 proved the passage of cvanid of potassium. Since 
then conclusive evidence has been adduced of the transmission of many 
inorganic and organic salts, alcohol and other compounds. Moreover, 
the demonstration by Kronig and Filth that the freezing points of both 
the maternal and foetal blood are identical, indicates that they both 
possess the same osmotic pressure, and consequently that osmosis can 
occur equally readily in either direction. Nicloux summarized our knowl¬ 
edge upon the subject up to 1909, and among other substances men¬ 
tioned iodid and bromid of potassium, phosphorus, the salts of mercury, 
copper, arsenic, and lead, carbolic acid, salicylate of sodium, quinin, 
morphia, atropin, and urea. 

Slemons and his associates—Morriss, Morse, Stander, Bogert and 
Curtis, have clearly shown that such excrementitious substances as urea, 
non-proteid nitrogen, ammonia, and uric acid are present in the same 
concentration in both the maternal and foetal blood and therefore must 
pass from one to the other by simple osmosis; while Plass, and Hunter 
and Campbell have made similar observations in the case of creatinine 
and creatin. On the other hand, Slemons and his associates have shown 
that the content in amino acids is higher in the foetal than in the ma¬ 
ternal blood, while the reverse holds good for glucose. They assume that 
both of these substances are transmitted by osmosis, but that the 
higher content in amino acids indicates that they are in some way 
"fixed’'* by the foetal blood. Furthermore, they hold that the higher 
glucose content of the maternal blood represents a mechanism, which 
insures a constant osmotic flow of this important substance to the less 
concentrated blood of the foetus. 

On the other hand, they hold that lipoids do not pass the placental 
filter, and that the fat required by the foetus is built up from glucose. 
They base this conclusion upon the fact that, while the fat content of 
the maternal blood is definitely increased during pregnancy, and always 
exceeds that of the foetal, no fixed ratio can be established between the 
two. Consequently, Slemons and Stander hold that the increased lipoid 
content of the maternal blood should be regarded as a preparation for 
lactation, but plays no part in the nutrition of the foetus in utero. 
Stander and Tyler have also pointed out that great caution should be 
exercised in drawing conclusions from analyses of the foetal and ma¬ 
ternal blood, unless the moisture content is determined at the same time, 
as variations in this respect may lead to such changes in concentration 
as to vitiate the deductions. 

Plass in this clinic has studied the relations of calcium and phosphoric 
acid, and found that the former is more abundant in the foetal than in 
the maternal blood, which is what one would expect when the need for 
calcium in the formation of the foetal skeleton is borne in mind. At 





PHYSIOLOGY OF THE FCKTUS 


171 


she same time, study of the phosphoric acid relations may lead to 
erroneous conclusions unless all of the factors concerned are critically 
eonsidered. His analyses showed that the total phosphorus content was 
much greater in the maternal blood; but, on the contrary, when its lipoid 
and inorganic and organic fractions were differentiated, totally different 
conclusions became inevitable, and it appeared that the lipoid phosphorus 
did not pass to the foetus at all, while the inorganic and organic fractions 
did, and were present in considerably larger quantities in the foetal 
blood. 

Upon summarizing these observations, it is apparent that the various 
excrementitious substances and glucose follow the laws of simple osmosis, 
that fat is not transmitted at all, and that the amino acids, calcium, and 
inorganic and organic phosphorus are more abundant on the foetal side, 
so that if they are transmitted by osmosis some mechanism must exist 
for their fixation in the foetal blood. Otherwise, it must be assumed 
that the chorionic epithelium must exert some selective activity, such 
as Cunningham has demonstrated in the cat, in which sodium ferro- 
cyanide readily passes into the foetal blood while iron ammonium citrate 
does not. 

It is now generally believed that the passage of formed substances 
does not occur, unless the material has first undergone marked changes 
under the influence of the chorionic epithelium, or when the placenta 
presents lesions. The work of Bonnet, Hofbauer, and others clearly 
shows that in various animals such substances as iron, fat, and al¬ 
buminous substances, are taken up by the syncytium, and after under¬ 
going radical changes are eventually passed on to the foetal circulation. 
Our knowledge upon the subject was well summarized by Hofbauer in 
1909, while Goldmann advanced it still further in 1912 during the 
course of his researches upon “vital staining.'” The work of Wislocki 
and Shimidzu has clearly shown that colloidal dyestuffs are unable to 
pass the placental filter unless their particles are extraordinarily minute 
in size. Iron is taken up by the trophoblast in the form of hemoglobin 
derived from hemolyzed maternal blood, and by appropriate biochemical 
methods can be demonstrated in the epithelium and stroma of the villi 
on its way to the foetal vessels. 

It has already been pointed out that in man fats probably do not pass 
through the placenta at all, but in certain animals it may be broken down 
in the outer portion of the syncytium into its constituents, which are 
later recombined just as in the intestines. This was shown conclusively 
by Hofbauer, who, after feeding pregnant animals with fat stained 
with Sudan red, found that characteristically stained fat in the inter¬ 
villous spaces, but only unstained fat was demonstrable in the syncytium 
and stroma of the villi. 

Albuminous substances are not absorbed as such, but are likewise 
broken down into simpler compounds, which are recombined alter passing 
into the foetal blood. It is now believed that they are resolved into their 
constituent amino acids, but Hofbauer and others could only demonstrate 
the presence of albumoses. 

Accordingly, it appears that the passage of organic substances through 







172 


THE FCETUS 


the placenta is accomplished by processes analogous to those occurring 
in the intestines, and that the syncytium is not only able to change many 
substances, but also has definite powers of selection. Plausibility is lent 
to such a view by the discovery by Bergell and Falk, Liepmann, Lockhead, 
and others of the presence of proteolytic, lipolytic, glycolytic, and oxidiz¬ 
ing ferments in the chorionic villi, more particularly in the syncytium. 

Although Claude Bernard, as early as 1859, demonstrated the pres¬ 
ence of glycogen in the placenta, its significance has only recently been 
appreciated. The investigations of Driessen, Jaretsky, and others have 
shown that before each menstrual period it is deposited in considerable 
quantities in the endometrium apparently in anticipation of the nutrition 
of the ovum. Moreover, in the first half of pregnancy, large quantities 
of glycogen are found not only in the decidua but also in the syncytium, 
cell nodes, and trophoblastic islands of the placenta, so that these struc¬ 
tures in all probability store glycogen and give it up to the foetus when¬ 
ever sugar is needed. 

Great caution must be exercised in applying to man, or even to 
other animals, conclusions drawn from observations or experiments upon 
animals of another species, on account of the remarkable differences in 
the structure of the placenta in even closely related species. It should 
always be remembered that in the semi-placentae of swine, cattle and 
sheep there is no possibility of the transfer of materials from the ma¬ 
ternal to the foetal blood by means of osmosis, but that the nutrition 
of the foetus is effected by direct absorption by the chorionic epithelium 
of the so-called uterine milk—the secretion of the uterine glands; and 
that in the dog and cat the conditions are by no means analogous to 
those obtaining in man. For example, in the latter animals it is not 
unusual to observe maternal erythrocytes in the process of digestion 
within the bodies of the high columnar, chorionic, epithelial cells, those 
nearest the surface presenting a normal appearance, while those at the 
basal portion of the cells have undergone almost complete dissolution. 

The work of Polano, Wegelius, and others has shown that many toxins 
and antitoxins are transmitted through the placenta—notably those of 
diphtheria, tetanus, colon and typhoid. Furthermore, Wegelius has 
proved that such transmission is not mere filtration or osmosis, but is 
due to some selective action on the part of the syncytium; as, after in¬ 
ducing active or passive immunity in the mother, he was able to demon¬ 
strate in certain cases that the antibody titer was higher in the foetal 
than in the maternal serum. 

. The question as to whether the placenta acts as an efficient filter 
against bacteria has given rise to a great deal of discussion, but at present 
the consensus of opinion is that such transmission occurs but rarely, and 
usually only in connection with some distinct lesion of the organ. The 
occurrence of intra-uterine smallpox was urged by John Hunter and 
many subsequent observers as proof in support of the affirmative view. 
Formerly it was not infrequent for mothers who suffered from smallpox 
during pregnancy to give birth to children bearing marks of the disease, 
and one of the most celebrated cases of this character was that of 
Mauriceau, the well-known obstetrician of the seventeenth century, who 








PHYSIOLOGY OF THE FOETUS 173 

! was born pock-marked. The significance of this occurrence, however, is 
by no means clear, inasmuch as we are not as yet acquainted with the 
materies morbi concerned. 

Lubarsch has shown that the organisms of anthrax, pneumonia, 

! typhoid fever, relapsing fever, and the various infections due to pyogenic 
organisms may be transmitted now and again, but regards such an oc¬ 
currence as exceptional. This is particularly well shown in tuberculosis, 
but out of the large number of tuberculous women who are delivered 
every year, Hauser in 1898 was able to collect only 18 who had given 
birth to children or placentae which gave evidence of the disease. Like¬ 
wise, in none of the placentae from tuberculous women which I have 
examined have I been able to find lesions in the foetal portion, even 
when the decidua was affected by the disease. 

In typhoid fever, on the other hand, it would appear that the trans¬ 
mission of organisms occurs frequently. Speier, in 1897, found the 
specific bacilli in the organs of a foetus whose mother was suffering 
with typhoid fever, and F. W. Lynch, in 1902, reported a case of the 
same character from my service. Since then we have repeatedly made 
similar observations, and Hicks and French noted such a transmission 
in 10 out of 30 cases, so that it is now generally recognized as a fre¬ 
quent concomitant of the disease. 

In other affections it would appear that transmission never occurs 
from mother to foetus. Thus, in malaria there is no evidence that the 
specific parasites can pass from the maternal to the foetal blood. 

The transmission of materials from the foetus to the mother has also 
been experimentally demonstrated for animals. Thus Savory and Gus- 
serow showed, by injecting strychnin into embryos still within the uterus, 
that the mother died within a short time from strychnin poisoning. 

: Similar results were also obtained hv Preyer with hydrocyanic acid, and 
by Nicloux with alcohol. 

The Nature and Functions of the Amniotic Fluid .—In addition to 
the materials received from the placenta, it is generally believed that the 
foetus obtains a great part of the fluid necessary for its development from 
that contained in the amniotic sac. Spiegelberg, Ahlfeld, Zweifel, and 
others have demonstrated that considerable quantities of it are swallowed, 
inasmuch as they found lanugo hairs, epidermic cells, etc., in the stomach 
and intestines of the foetus. Ahlfeld believes that the amniotic fluid is 
swallowed in such large quanfities that even the small amount of al¬ 
bumin which it contains aids in the nutrition of the foetus; hut this 
point is very doubtful. Besides this function, the amniotic fluid plays 
an important part by surrounding the foetus with a medium of constant 
temperature, which serves to prevent loss of heat, while at the same time 
affording a protection against sudden shocks from without. It also sub¬ 
serves an important function by preventing the formation of adhesions 
between the foetus and the walls of the amniotic sac, which, when they 
occur, often give rise to serious deformities. 

According to Hoppe-Seyler, the amniotic fluid is clear, alkaline in 
reaction, having a specific gravity of 1.006 to 1.008, and consisting of 
98.48 per cent, water, 0.19 per cent, albuminoid material, 0.556 per cent. 






174 


THE FCETUS 


soluble inorganic salts, 0.8 per cent, extractives, and 0.024 per cent, 
insoluble organic salts. 

Unfortunately it is impossible at this time to make positive state¬ 
ments concerning the origin of the amniotic fluid in women, and those 
interested in the subject will find our knowledge up to 1912 well sum¬ 
marized in the articles of Ahlfeld and Wagner. From time to time 
four main views have been advanced as to its origin: (1) foetal urine; 
(2) transudation from maternal blood; (3) secretion through the am¬ 
niotic epithelium, and (4) a mixed origin. 

The first view was advocated in the seventeenth century by Portal, 
and has had many adherents until recently. Practically all investigators 
agree that the foetal kidneys are capable of functioning in the later 
months of pregnancy, and undoubtedly do so under abnormal conditions, 
notably in certain cases of uniovular twin pregnancy. On the other hand, 
it is extremely doubtful whether they function at all under normal condi¬ 
tions, as it would appear improbable that the foetus would swallow its 
own urine. Moreover, the fact that the amniotic fluid is present in 
very early ova, even before the development of the embryonic area, 
as well as before the development of the foetal kidneys, clearly 
indicates that in early pregnancy at least some other origin must 
be sought. Furthermore, the occurrence of dropsical ova, in which all 
trace of the foetus has disappeared, while the amniotic sac is distended 
by fluid, forces us to a similar conclusion. Finally analysis of the am¬ 
niotic fluid shows that it contains very small quantities of urea, and 
indicates, if it is foetal urine, that it differs very markedly from that 
excreted during extra-uterine life. 

The question has also been approached experimentally, particularly by 
Schaller. This observer availed himself of the well-known fact that the 
administration of phloridzin gives rise to a transitory diabetes, which re¬ 
sults from the action of the drug upon the renal epithelium and not from 
changes produced in the blood. He showed that after the drug had been 
injected into the mother its presence could readily be demonstrated in 
the tissues of the foetus, while the amniotic fluid rarely contained traces 
of sugar, which should have been present in large quantity had the foetal 
kidneys functioned. 

Until very recently many authorities believed that the amniotic fluid 
was in great part a transudation from the maternal vessels. Probability 
is lent to such a view by the fact that an excessive quantity of amniotic 
fluid is present in certain dropsical conditions of the mother, but more 
particularly by the results following the injection of certain substances 
into the maternal circulation. When potassium iodid or sodium indigo 
sulphate is so injected the substance promptly appears in the amniotic 
fluid, but no trace can be demonstrated in the foetal kidneys. Further¬ 
more, glucose is frequently present in the amniotic fluid of women suf¬ 
fering from glycosuria, while it is uniformly absent in normal preg¬ 
nancy. 

On the other hand, the fact that Zangemeister and all subsequent 
investigators have found that the freezing point of the amniotic fluid is 
lower than that of the maternal serum clearly indicates that the former 





PHYSIOLOGY OF THE FCETUS 


175 


cannot be derived from the latter by filtration. Furthermore, the bio¬ 
chemical investigations of Polano show that the amniotic fluid does not 
contain certain antibodies found in the maternal serum, which should be 
present were the former a mere transudate. Likewise, the amniotic fluid 
and maternal serum lack a staphylolysin which is present in the foetal 
urine. Consequently, he concluded, since the amniotic fluid was derived 
neither from the maternal serum nor from the foetal urine, that the only 
origin possible must be a direct secretory action on the part of the 
amniotic epithelium. 

Particularly in certain cases of hydramnios, histological examination 
by Polano, Bondi, Mandl, and others shows that certain changes occur 
in the amniotic epithelium which can only be interpreted as manifesta¬ 
tions of secretory activity. Likewise, the investigations of Goldmann, 
and Evans upon “vital staining” point to a similar conclusion. Upon 
injecting pregnant animals with pyrrol-blue, these observers found that 
the internal organs and external surface of the mother took on a blue 
stain, while in the foetus the coloration was limited to the external surface 
and to the lining of the intestinal canal. At the same time the amniotic 
fluid was blue and the amniotic epithelium pigmented. They accord¬ 
ingly concluded that the pigment gained access to the amniotic fluid 
through the amniotic epithelium, and that the pigmentation of the foetus 
was due to the fact that it was bathed by and also swallowed the colored 
liquor amnii. That the latter could not represent foetal urine was 
demonstrated by the absence of pigment from the vesical and renal 
epithelium. 

Finally, it should be borne in mind that a great part at least of 
the amniotic fluid may represent a transudation through the surface of 
the foetus or through the vessels of the cord; and, furthermore, as shown 
by the experiments of Wolff, that the foetal kidneys may function if those 
of the mother become insufficient. Wagner, however, has shown that in 
experimental animals mere renal insufficiency on the part of the mother 
is not sufficient to cause the foetal kidney to function, but that this 
occurs only after double nephrectomy, or at least after the removal of 
three-quarters of the kidney substance. 

Accordingly, from the evidence at present available, it would appear 
that under normal conditions the amniotic fluid is derived primarily 
from the maternal serum, which is profoundly modified during its pas¬ 
sage through the amniotic epithelium; but that under abnormal condi¬ 
tions other sources, more particularly the foetal urine, will have to be 
taken into consideration. 

Respiratory and Digestive Functions .—It would appear that the 
foetus in utero requires a relatively small quantity of oxygen to support 
life, so there is but little tissue waste. Again, the fact that it is sur¬ 
rounded by amniotic fluid makes it necessary for the foetus to produce 
but little warmth, as only a small amount of energy is expended during 
its restricted movements.^ Its need of oxygen, however, is demonstrated 
fly the rapid occurrence of death, with symptoms of asphyxia, v hene\’ei 
the circulation of the umbilical cord is interfered with even for a short 

time. 






176 


THE FCETUS 


It has been demonstrated that the foetus actually produces warmth, 
as Wurster showed that its temperature exceeded that of the interior of 
the uterus by 0.5° C. or 0.9° F. Champion, in 1903, arrived at a similar 
conclusion, and put the difference at 1° F. 

Very little is known concerning the functions of the intestinal tract 
of the foetus, though it has been demonstrated that the stomach contains 
pepsin and rennin after the fifth month, their presence indicating a cer¬ 
tain amount of glandular activity. The large amount of blood which 
circulates through the liver would go to show that this organ serves some 
important purpose, and the formation of bile is conclusively demonstrated 
by the presence of biliary materials in the meconium. 

While the foetus remains in the uterus its movements are restricted 
within narrow limits, though such undoubtedly occur, being felt by the 
mother as “life” from the middle of pregnancy, and at a little later 
period by the physician when he places his hand upon the abdomen. 
Ahlfeld demonstrated, by the use of the sphygmograph, that the foetus 
makes very rapid superficial movements—at the rate of sixty to the 
minute—which he considered represented an abortive type of respiration; 
but his conclusions have not been generally accepted, and we are still 
in doubt as to the significance of his observations. 

Sex of the New-born Child. —Statistics show that more boys are born 
at full term than girls, the proportion, according to the figures given by 
Rauber, being 106 to 100. Ahlfeld has pointed out that this ratio is still 
further increased in elderly primiparae. Furthermore, it is well known 
that in abortions and premature labors the males still further outnumber 
the females. In 1,200 specimens of abortion in the Carnegie Laboratory 
of Embryology, Schultz found that the sex ratio was 110 to 100, and 
stated that Auerbach had estimated that it was 125 to 100 at the onset 
of pregnancy, thus indicating a specifically greater mortality in the case 
of males. For these reasons, Schultz suggested the advisability of dis¬ 
tinguishing between primary, secondary and tertiary sex ratios: the 
first representing the conditions immediately following conception, the 
second those at full term, and the third those at any specifically 
chosen period of later life. 

Until recently we were almost absolutely ignorant concerning the 
causation of sex, though it was generally believed that it did not become 
established until some time after fertilization. Recent investigations, on 
the other hand, clearly show that this is not the case, but that sex is 
determined in the germ cells, either primarily or immediately after their 
union, so that it has become immutable by the time segmentation of the 
ovum begins. 

In the first place, support is lent to such a view by observations upon 
twin pregnancy in human beings. It has long been known that these 
result either from the fertilization of one or of two ova, and that a posi¬ 
tive distinction can be made bv the studv of the foetal membranes. In 
the first case the children are always of the same sex, whereas in the 
latter the sex may or may not be the same. Furthermore, still more 
striking evidence is afforded by the armadillo. In this animal each litter 
consists of four young which are derived from a single ovum, as is shown 





SEX OF THE NEW-BORN CHILD 


177 


by the fact there is only one placenta, one chorion, and four amnions. 
All the young in each litter are always of the same sex. 

Such observations simply show that the sex had been determined 
before the beginning of segmentation, but give no information as to the 
mechanism of its determination, and leave us doubtful whether it had 
been predetermined in the ovum or in the spermatozoon, or was due 
to changes taking place at the time of fertilization. 

Morgan, and Doncaster have given excellent reviews of the subject, 
and have pointed out that all these eventualities are possible. The latter 
lays particular stress upon the influence of the egg, and points out that 
male and female eggs occur in many species, and have been demon¬ 
strated in phylloxera, hydatina and certain gall flies. In these animals 
the two types of eggs can be readily distinguished, and as they develop 
by parthogenesis there is no possibility of any influence being exerted 
by the spermatozoa. 

On the other hand, Morgan, Wilson, Stevens, Boveri, and others con¬ 
tend that in many species the determining factor must be attributed to 
the spermatozoon. These investigators have carefully studied the ar¬ 
rangement of the chromosomes in numerous insects, and in some species 
have discovered that they are differently arranged in the germ cells. 
Thus, in the oocytes, the chromosomes are always in pairs of similar ap¬ 
pearance, while in the spermatocytes three types may be observed. In 
the first type one of the chromosomes is without a mate; in the second, 
the chromosomes in one pair may vary in size, one being larger than its 
mate; while in the third, no difference can be detected. Accordingly, 
when reduction occurs in the formation of the spermatozoa, two varieties 
of spermatozoa will occur in each of the first two types, while in the 
third there will be no variation. In the first type one variety of 
spermatozoa will contain one less chromosome than the other; in the 
second both varieties will contain the typical number, but one will possess 
an aberrant, or small chromosome, while in the other all the chromosomes 
will be similar. According to WTlsoirs theory, sex will depend upon 
which variety of spermatozoon effects fertilization: those with identical 
chromosomes giving rise to females, and those lacking a chromosome, or 
provided with a small one, giving rise to males. Whether the determina¬ 
tion is effected solely by the spermatozoon, or whether it merely brings 
to the ovum certain substances which set in motion tendencies which 
already existed, is not yet known. In the latter event, the determination 
of sex must eventually prove to be a function of the ovum. 

Reference has already been made to the investigations of Theophilus 
S. Painter upon spermatogenesis in man, which apparently show beyond 
peradventure that the spermatocytes of the first order contain 48 
chromosomes, one of which is of the “x-y” variety (Figs. 176, a and l). 
Consequently, when the reduction division occurs, two types of sperma¬ 
tozoa will develop, each containing twenty-four chromosomes, but differ¬ 
ing from one another by the fact that one type contains an x chromosome 
and the other a y chromosome. As all of the chromosomes of the mature 
ovum are of one type, it is apparent that after fertilization we may have 
to deal with two types of zygotes—one containing 46 typical and 2 x 



178 


THE FCETUS 


chromosomes, while the other contains an x and a y chromosome, the 
first developing into a female and the second into a male. In other 
words, for practical purposes, spermatozoa containing the x chromosome 
may be regarded as female and those containing the y chromosome as 
male spermatozoa. 

As each spermatocyte, at the reduction division, gives rise to two 
spermatozoa—one of which is male and the other female it would 
appear that male and female children should be produced in equal num¬ 
bers, and yet we know that the primary sex ratio is 100 females to 125 
males, which diminishes to a secondary ratio of 100 to 106 at the time 
of labor. Why this is so, we are unable to state; but such a result might 



Fig. 1 76A. — Portion of Human First 
Spermatocyte Spindle showing 
the X- Y Sex Chromosomes among 
the Tetrades (Painter). 


Fig. 176B.—First Maturation 
Division showing Segregation 
of X and Y Chromosomes to Op¬ 
posite Poles of the Human First 
Spermatocyte Spindle (Painter). 


be attributed to a selective mortality on the part of the female sperma¬ 
tozoa, whereby the probability of fertilization by spermatozoa containing 
the x chromosome would be reduced. Or, it might be supposed that 
such spermatozoa can fertilize the ovum only when it is relatively fresh, 
while those containing the y chromosome can fertilize it over a longer 
period. The latter supposition might afford an explanation for SiegeTs 
observation that coitus about the time the follicle ruptures usually re¬ 
sults in girls, while coitus just before or after the menstrual period 
usually results in boys. He assumes that in the first case the ovum is 
relatively fresh, while in the latter it is overripe when fertilized. His 
observations were made by studying the menstrual history of women 
who conceived following a short furlough of their husbands during the 
war. They are, however, too few in number to be conclusive, and quite 
likely are equally explicable by some other hypothesis. 

Whatever the correct explanation may be, there seems every ground 
for believing that in human beings sex is determined primarily by the 
type of spermatozoon by which fertilization is effected. 












LITERATURE 


179 


Further evidence in favor of such a view is afforded by the study of 
so-called sex-limited inheritance, in which abnormalities or diseases, such 
as color blindness or hemophilia are transmitted from a man to his 
grandsons through the intermediary of his daughters. It would, how¬ 
ever, lead too far afield to consider such problems, and those desiring 
further information are referred to special works on heredity. 

In 1897 Schenk startled the world by stating that sex could be deter¬ 
mined at will, as it was entirely dependent upon the condition of nutri¬ 
tion of the mother, and could therefore be influenced by appropriate 
dietetic treatment. The considerations just mentioned, however, show 
that his conclusions were visionary. 

Reference might also be made to the erroneous, but wide-spread, 
belief that boys develop from eggs coming from the right ovary and 
girls from the left. Rumley Dawson in a monograph which appeared in 
1917 attempted to prove that the two ovaries ovulated alternately, so 
that it was possible to control the sex provided the woman had previously 
given birth to a child. To do so, it was only necessary to remember 
that, at the first ovulation following labor, the ovum would come from 
the ovary which had not functioned at the last conception. Accordingly, 
if the child were a boy, the next ovum would be from the left ovary, 
so that by making the necessary calculation coitus could be had when 
the right or left ovary was to function, according as a boy or girl was 
desired. 

That such teaching is erroneous is demonstrated by the fact that 
women from whom one ovary has been removed continue to have chil¬ 
dren of either sex, and Murray, from my own material, conclusively 
showed the fallacy of such a belief. Moreover, I have for years made it 
a practice to note at caesarean sections which ovary contains the corpus 
luteum, and have found that it is a matter of indifference whether it is 
situated on the right or left side so far as the sex of the child is con¬ 
cerned. For example, in 64 observations the corpus luteum was found 
36 and 28 times in the right and left ovary respectively. In the first 
instance, there were 23 boys and 13 girls, while in the second there 
were 16 and 12 respectively, thereby conclusively demonstrating that 
children of either sex may develop from eggs coming from either ovary. 

LITERATURE 

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Ankle Joint at Birth. Am. J. Obst. & Gyn., 1921, 35-60. 

Ahlfeld. Die Geburten alterer Erstgeschwangerten. Archiv f. Gyn., 1872, iv, 

510-520. 

Ueber die Bedeutung des Fruchtwassers als Nahrungsmittel fur die Frucht. 

Berichte u. Arbeiten, Leipzig, 1885, ii, 22. 

Atem-bewegungen des Fotus. Lehrbuch der Geb., 1898, II. Aufl., 57. 

Zwanzig Betrachtungen fiber die Herkunft des Fruchtwassers. Zeitsclir. f. Geb. 

u. Gyn., 1911, Ixix, 91-116. 

Ascoli. Passirt Eiweiss die placentare Scheidewand. Hoppe-Seiler *s Zeitschr., 

xxxvi, 526. 


180 


THE FOETUS 


Bachimont. De la puericulture intrauterine au cours de la grossesse gemellaire. 
These de Paris, 1898. 

Ballantyne and Browne. The Problem of Foetal Post-maturity and Prolongation 
of Pregnancy. J. Obst. and Gyn. Brit. Emp., 1922, xxix, 177-238. 

Bergell u. Falk. Ueber die Funktion d. Placenta. Miinchener ined. Wochenschr., 
1908, No. 43. 

Blecard. Quoted by Schroeder, Lehrbuch der Geburtshiilfe, 1899, XIII., Aufl., 67. 

Bondi. Zur Histologie des Amionepithels. Zentralbl. f. Gyn., 1905, 1075-1076. 

Bonnet. Ueber Syncytien, Plasmodien u. Symplasma in der Placenta, etc. 
Monatsschr. f. Geb. u. Gvn., 1903, xxiii, 1-51. 

Boveri. Ueber das Verhalten d. Geschlechtschromosomen bei Hermaphroditismus. 
Verh. d. phys.-med. Gesellsch. z. Wurzburg, 1911, N. F., xli. 

Calkins. Morphometry of the Human Fetus. Am. J. Obst. and Gym, 1922, iv, 
109-130. 

Cohnstein und Zuntz. Untersuchungen liber das Blut, den Kreislauf und die 
Athmung beim Saugethier-Fotus. Ptliiger’s Archiv, 1884, xxxiv, 173. 

Cunningham. Studies in Placental Permeability, II. Am. Jour. Physiol., 1922, 
lx, 448-460. 

Dawson. The Causation of Sex in Man. New York, 1917. 

Doncaster. The Determination of Sex. Cambridge and New York, 1914. 

Driessen. Ueber Glykogen in d. Placenta. Archiv f. Gyn., 1907, lxxxii, 278- 
301. 

Glykogenproduetion, eine physiologische Funktion der Uterusdriisen. Zentralbl. 
f. Gyn., 1911, 1308-1313. 

Dubois. Les gros enfants. These de Paris, 1897. 

Fehling. Beitrage zur Physiologie des placentaren Stoffverkehrs. Archiv f. 
Gyn., 1877, xi, 523-557. 

Goldmann. Vitale Farbung. Tiibingen, 1909. 

Die aussere und innere Sekietion im Lichte der “vitalen Farbung. ” Beitrage 
z. klin. Chirurgie, 1912, lxxviii, 1-108. 

Haase. Charite-Annalen, ii, 686. 

Hicks and French. Lancet, 1905, i, 1491, 1493. 

His. Anatomie menschlicheu Embryonen. Leipzig, 1880-1885. 

Hofbauer. Grundziige einer Biologie der menschl. Plazenta. Wien, 1905. 

Die menschliche Placenta als Assimilations-organ. Volkmann’s Samml. klin. 
Vortrage, 1907, Nr. 454. 

Die biologische Bedeutung d. Placenta. Zeitschr. f. Geb. u. Gyn., 1909, lxiv, 
668 - 686 . 

Holzbacii. Ueber den Wert der Merkmale zur Bestimmung der Reife der Neuge- 
borenen. Monatsschr. f. Geb. u. Gyn., 1906, xxiv, 429-445. 

Hoppe-Seiler. Physiologische Chemie. 1877, I. Theil, 609. 

Hunter and Campbell. Placental Transmission of Creatinine and Creatin. Jour. 
Biol. Chem., 1918, xxxiv, 5. 

Jackson. On the Prenatal Growth of the Human Body. Am. J. of Anat., 1909, 
ix, 119-169. 

Kronig und Futh. Vergleichende Untersuchungen iiber den osmotisehen Druck 
im miitterlichen und kindlichen Blute. Monatsschr. f. Geb. u. Gyn., 1901, 
xiii, 39-54. 

Lea. The Sagittal Fontanelle in the Heads of Infants at Birth. Trans. London 
Obst. Soc., 1898, xl, 263-270. 

Liepmann. Zur Biologie der Placenta. Zeitschr. f. Geb. u. Gyn., 1905, lvi, 232-243. 

Lubarsch. Uebertragung von Infelctionskrankheiten von Aseendenten auf De- 
scendenten. Lubarsch-Ostertag, Ergebnisse der allg. Path. u. path. Anat., 
1896, i, 427-455. 



LITERATURE 


181 


Ludwig. Sectio caesarea bei iibermassig entwickelter todtfauler Frucht. Zen- 
tralbl. f. Gyn., 1896, 64-65. 

Lynch. Placental Transmission, with Report of a Case during Typhoid Fever. 

Johns Hopkins Hospital Reports, 1902, x, 203-222. 

Mandl. Weitere Beitriige z. Kenntniss der sekretorische Tatigkeit des Amnion- 
epithels. Zeitschr. f. Geb. u. Gyn., 1906, lviii, 249-257. 

Mayer. Yersuche welche den Uebergang tropfbarer Fliissigkeiten von der Mutter 
an und in den Foetus erweisen. Med. Chirurgische Zeitung, 1817, ii, 431. 

■ Michel. Sur la composition organique et minerale de foetus et du nouveau-ne. 

L’Obstetrique, 1900, v, 252-261. 

Morgan. Heredity and Sex. New York, 1913. 

Murray. The Relation of the Supplying Ovary to the Causation of Sex. Bull. 

I Johns Hopkins Hospital, 1918, xxix, 275-281. 

Nicloux. Sur le passage des substances chimiques de la mere au foetus. 

L ’Obstetrique, 1909, N. S. ii, 840-865. 

Painter. The Spermatogenesis of Man. Jour. Exp. Zoology, 1923, xxxvii, 
Piering. Ueber die Grenzen des Korpergewichtes Neugeborener. Monatsschr. 
f. Geb. u. Gyn., 1899, x, 303-311. 

Plass. The Various Phosphoric Acid Compounds in Maternal and Foetal Serum. 
Jour. Biol. Chem., 1923. 

Total Creatinine in Plasma, Whole Blood, and Corpuscles of Mother and Foetus, 
Bull. Johns Hopkins Hospital, 1917, xxviii, 297. 

Pinard. Note pour servir a l’histoire de la puericulture pendant la grossesse. 

Annales de gyn. et. d’obst., 1898, 1, 81-89. 

Pohlman. The Course of the Blood through the Heart of the Foetal Mammal. 
Anat. Record, 1909, iii, 75-109. 

Polano. Exp. Beitrag zur Biologie der Schwangerschaft. Wurzburg, 1904. 
Ueber die sekretorische Tatigkeiten des amniotischen Epithels. Zentralbl. f. 
Gyn., 1805, 1203-1206. 

Preyer. Specielle Physiologie des Embryo. Leipzig, 1885. 

Rauber. Der Ueberschuss an Knabengeburten u. seine biologische Bedeutung. 
Leipzig, 1900. 

Riggs. A Comparative Study of White and Negro Pelves, etc. Johns Hopkins 
Hospital Reports, 1904, xii, 42-54. 

| Savory. Quoted by Preyer. 

Schaller. Ueber Phloridzin-diabetes Schwangerer, etc. Archiv f. Gyn., 1899, 
lvii, 548-565. 

Schenk. Einfluss auf das Geschlechtsverhaltniss, II. Aufl., Magdeburg, 1898. 
Schroeder. Physiologie des Fotus. Lehrbuch der Geb., 1899, XIII. Aufl., 75. 
Schultz. Sex Incidence in Abortions. Contributions to Embryology. Carnegie 
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Schmidzu. On the Permeability to Dyestuffs of the Placenta, etc. Am. J. Physiol., 
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Siegel. Gewollte und ungewollte Schwankungen der weiblichen Fruchtbarkeit. 
Berlin, 1917. 

Slemons. The Nutrition of the Foetus. New Haven, 1919. 

Slemons and Standee. The Lipoids of the Maternal and Foetal Blood at the 
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Spiegelberg. Fruchtwasser. Monatsschr. f. Geburtskunde, 1861, xviii, -j74- 

400. 

Stander and Tyler. The Moisture and Ash of Maternal and Foetal Blood. Surg., 
Gyn. and Obst., 1920, xxxi, 276-281. 





182 


THE FCETUS 


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f. Gyn., 1905, lxxiv, 569-619. 

Stevens. Studies in Spermatogenesis. Carnegie Inst. Publication, Oct., 1906, 
pp. 33-74. 

Streeter. Weight, Sitting Height, etc., and Menstrual Age of the Human Embryo. 
Publication 274 of the Carnegie Institution of Washington. 

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Wagner. Beitrage z. Frage d. Herkunft des Fruchtwassers. Leipzig u. Wien, 
1913. 

Wegelius. Antikorperiibertiagung von Mutter auf Kind. Archiv f. Gyn., 1911, 
xciv, 265-300. 

Williams. A Critical Analysis of Twenty-one Years’ Experience with Caesarean 
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Wilson. Studies on Chromosomes. J. Exp. Zoology, 1906, iii. 

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Winckel. Neue Untersuchungen iiber die Dauer der menschlichen Schwanger- 
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Wislocki. The Fate of Solutions and Colloids Injected into the Mammalian 
Embryo. Bull. Johns Hopkins Hosp., 1921, xxxii, 93-97. 

Wolff. Fruchtwasser, Oppenheimer’s Handbuch d. Biochemie, 1910, iii, 709-741. 

Wurster. Beitrage zur Tocothermometrie. D. I., Zurich, 1870. 

Zaretsky. Le glycogene dans le placenta discoide. L’Obstetrique, 1911, N. S. iv. 

Ziegenspeck. Zur Fcetalkreislauf. Gyn. Rundschau, 1910, iv, 75-109. 

Zweifel. Untersuchungen iiber das Meconium. Archiv f. Gyn., 1875, vii, 474- 
490. 

Die Respiration des Fotus. Archiv f. Gyn., 1876, ix, 291-305. 

Der Uebergang von Chloroform und Salicylsaure in die Placenta. Archiv f. 
Gyn., 1877, xii, 235-257. 


SECTION III 

PHYSIOLOGY OF PREGNANCY 


CHAPTER YI 

CHANGES IN THE MATERNAL ORGANISM RESULTING FROM 

PREGNANCY 

It should be constantly borne in mind that pregnancy is not a mere 
local condition affecting the genitalia, but is a process associated with 
fundamental changes in the entire organism. Ordinarily, one fails to 
realize how radical these changes are, and to how great an extent the 
child-bearing woman differs from man. The contrast was strikingly 
illustrated by Sellheim when he estimated that a woman who has borne 
six children has produced by her generative function—including men¬ 
struation, but excluding the production of milk—an amount of tissue 
twice as great as her original weight. 

Every portion of the maternal organism reacts to a greater or lesser 
extent under the influence of pregnancy. Formerly, these changes were 
attributed in great part to nervous impulses originating in the pregnant 
uterus, but more extended clinical observation and experimental work 
show that such is not the case, and indicate that such changes can be 
explained only by the supposition that they are in some way connected 
with the circulation in the blood of substances concerning whose nature 
we are as yet ignorant. 


UTERUS 

Naturally the most apparent changes are observed in the generative 
tract, and especially in the uterus, which undergoes a very great increase 
in size. Thus, it is converted from a small, almost solid organ, 6.5 
centimeters long, into a thin-walled, muscular sac, capable of containing 
the foetus, placenta, and a large quantity of amniotic fluid, and at the 
end of pregnancy is about 32 centimeters long, 24 centimeters wide, and 
22 centimeters deep. Krause estimated that its capacity is increased 519 
times. A corresponding increase in weight is also observed, the uterus 
at full term weighing in the neighborhood of 1,000 grams (2 pounds), 
as compared with 30 grams (1 ounce) in the virginal condition. 

This enlargement is due principally to the hypertrophy of preexisting 
muscle cells, but partly also to the formation of new ones during the 
earlier months of pregnancy. The fully developed muscle fibers are from 

183 



184 


CHANGES IN TIIE MATERNAL ORGANISM 


2 to 7 times wider and from 7 to 11 times longer than those observed in 
the non-pregnant uterus, measuring 0.009 to 0.014 X 0.2 to 0.52 milli¬ 
meter in the former, as compared with 0.005 X 0-05 to 0.07 millimeter in 
the latter. According to the researches of Luschka and Veit, the forma¬ 
tion of new muscular fibers is limited to the first three or four months 
of pregnancy. 

With the increase in the number and size of the muscle fibers is asso¬ 
ciated a marked development of elastic tissue. D’Erchia has shown that 
it forms a network about the various muscle bundles, which hypertrophies 

with advancing preg¬ 
nancy, and thus adds 
materially to the 
strength of the uterine 
walls. At the same 
time there is a great 
increase in the size of 
the blood vessels, espe¬ 
cially the veins, which, 
in the neighborhood of 
the placental site, be¬ 
come converted into 
large spaces, the so- 
called placental sin¬ 
uses. Marked hyper¬ 
trophy of the lympha¬ 
tic and nervous supply 
of the uterus also takes 

Fig. 177. — Muscle Fibers from Non-pregnant and place, which is veil 
Pregnant Uterus (Sappey). illustrated by the in¬ 

crease in size of 

Frankenhausers cervical ganglion from 2 X 2.5 to 3.5 X 6 centimeters. 

During the first few months the hypertrophy of the uterus, in all 
probability, is brought about by the circulation of certain substances 
derived from the ovum or corpus luteum. That it is not directly due to 
the presence of the ovum in the uterine cavity is shown by the occurrence 
of precisely similar changes in extra-uterine pregnancy, when the ovum 
is implanted in the tube or ovary. After the third month, however, the 
increase in size is in great part mechanical, and is due directly to the/ 
pressure exerted by the growing product of conception. 

During the first few months of pregnancy the uterine walls are con¬ 
siderably thicker than in the non-pregnant condition, but as gestation 
advances they gradually become thinner, so that at the end of the fifth 
month they are from 3 to 5 millimeters in thickness. This measurement 
is retained throughout the succeeding months, so that at term the walls 
of the body of the uterus are rarely above 5 millimeters thick, and oc¬ 
casionally they measure considerably less. Consequently the organ soon 
loses the firm, almost cartilaginous consistence which is characteristic 
of the non-pregnant condition, and becomes converted into a muscular 
sac having very thin, soft and readily compressible walls. This is well 













































UTERUS 


185 


demonstrated by the ease with which the foetus can usually be palpated 
m the later months, and by the readiness with which the uterine walls 
yield to the movements of the foetal extremities. Furthermore, it is 
frequently possible at abdominal operations to observe shallow depres¬ 
sions upon the surface of the uterus, which have resulted from the pres¬ 
sure of the intestines upon it. 

The enlargement of the uterus is not symmetrical, but is most marked 
m the fundal region. This can readily be appreciated by observing the 
relatu e positions of the insertions of the tubes and ovarian ligaments, 
which in the early months of pregnancy are almost on a level with the 



Fig. 178. —External Muscular Layer of Fig. 179. —Internal Muscular Layer 
Pregnant Uterus (H lie). of Pregnant Uterus (Helie). 


fundus; whereas in the later months their attachments are found at 
points slightly above the middle of the organ. 

The position of the placenta also exerts a determining influence upon 
the extent of the hypertrophy, the portion of the uterus to which it 
is attached enlarging more rapidly than elsewhere, as is clearly shown 
by the position of the uterine ends of the round ligaments, which are 
close together when the placenta is inserted upon the posterior, and far 
apart when it is upon the anterior wall. 

Arrangement of the Muscle Fibers.—Ever since the time of Vesalius, 
considerable attention has been devoted to the arrangement of the muscle 
fibers in the pregnant uterus. Among the numerous investigators whose 
careful studies on this subject deserve special mention are William 
Hunter in England; Madame Boivin, Deville, and Helie in France; 
Roederer, Luschka, Henle, Hoffmann, Bayer, and Hofmeier. 

According to Luschka and Henle, the musculature of the pregnant 
uterus is arranged in three strata ;• ternal hoodlike layer, which 












186 


CHANGES IN THE MATERNAL ORGANISM 


arches over the fundus and extends into the various ligaments; and an 
internal layer, consisting of sphincterlike fibers around the orifices of 
the tubes and the internal os; while lying between the two is a dense 
network of muscle fibers perforated in all directions by blood vessels. 

The most important contributions, however, we owe to Helie, Bayer, 
and Ruge. In the preface to his monograph Helie states that he had 
devoted twelve years to his investigations, and Bayer has been an in¬ 
defatigable worker upon the subject since 1886. 

According to Helie, the uterine musculature consists of three main 
layers, each of which is made up of several subsidiary divisions. The 
external layer is composed of two longitudinal or ansiform portions, 
between which lies a transverse layer. The internal layer is composed 

of two triangular por¬ 
tions running along the 
inner surface of the an¬ 
terior posterior walls of 
the uterus respectively, 
and connected by an 
archiform layer at the 
fundus, an obicular por¬ 
tion around each tubal 
opening and an annular 
layer around the internal 
os. The main portion of 
the uterine wall is formed 
by the middle layer, which consists of an interlacing network of muscle 
fibers, between which extend the blood vessels. Each fiber comprising 
this layer has a double curve, so that the interlacement of any two gives 
approximately the form of the figure “8.” As a result of such an arrange¬ 
ment, it happens that when the fibers contract after delivery they con¬ 
strict the vessels and thus act as living ligatures. 

Ruge pointed out that many of the layers which had been described 
by previous observers do not exist as such in the pregnant uterus, the 
appearances having resulted from the manner in which the dissections 
had been made. He showed that the muscle fibers composing the uterine 
wall, especially in its lower portion, overlap one another and are arranged 
like shingles on a roof, one end of each fiber arising beneath the perito¬ 
neal covering of the uterus, and extending obliquely downward and in¬ 
ward, to be inserted into the decidua, thus giving rise to a large number 
of muscular lamellae. The-various lamellae are connected with one 
another by short muscular processes, so that when the tissue is slightly 
spread apart it presents a sievelike appearance, which on closer examina¬ 
tion is seen to be due to the presence of innumerable rhomboidal spaces. 
Ruge attaches great importance to this arrangement of the muscle fibers, 
and believes Ahat it explains very satisfactorily the mechanism of the 
uterine contractions, and the manner in which the feltlike structure of 
the puerperal uterus is brought about. 

Changes in Size and Shape of the Uterus.—As the uterus increases in 
size, it also undergoes important modifications in shape. For the first 



Fig. 180. —Median Muscular Layer of Pregnant 
Uterus (Helie). 




UTERUS 


187 


few weeks its original pyriform outlines are retained, but the body and 
fundus soon assume a more globular form, which at the third or fourth 
month becomes almost spherical. After this period, however, the organ 
increases more rapidly in length than in width, and assumes an oval 
form, which persists until the end of pregnancy. 

The increase in the size of the uterus is limited almost entirely to 
its body, the cervix remaining practically unchanged until the onset of 
labor, so that throughout the course of pregnancy it appears as a mere 



Figs. 181a and 1816. —Same Full-term I-para in Vertical and Horizontal Position 

appendage to the enlarged body. Its most characteristic change consists 
in a marked softening, which is readily appreciated by the examining 
finger, and constitutes one of the physical signs of pregnancy, 
slight increase in size which can be noted is due in great part to increased 
vascularity, and depends only to a small extent upon hypertrophy of its 
muscle fibers. As a result, the secretion of the cervical glands becomes 
more copious and the cervical canal becomes filled with a plug of mucus. 
The changes occurring in it in the latter part of piegnancy v dl bt 
considered in detail when we take up the physiology of labor 
' As the body of the uterus becomes larger, the angle which it lorms 







188 


CHANGES IN THE MATERNAL ORGANISM 


with the cervix becomes more acute—in other words,, its physiological 
anteflexion is increased. By the fourth month the organ becomes too 
large to be contained in the pelvic cavity, and forms a tumor, the upper 
border of which reaches midway between the symphysis pubis and the 
umbilicus. As it becomes still larger, it comes in contact with the an¬ 
terior abdominal wall, displacing the intestines to the sides of the abdo¬ 
men, and gradually rises up until it almost impinges upon the liver. As 
the uterus leaves the pelvis for the abdominal cavity, considerable ten¬ 
sion is exerted upon the broad ligaments, which then become more or 
less unfolded at their median and lower portions and thus contribute 
to the mobility of the pelvic peritoneum, which is characteristic of 
pregnancy. 

The pregnant uterus possesses a considerable degree of mobility. 
Since its upper portion projects into and lies free in the abdominal 
cavity, and its lower portion is held in check by the cervical attachments, 
it readily changes its position. With the woman in a standing posture 
its longitudinal axis corresponds closely with that of the superior strait, 
the organ resting in great part upon the anterior abdominal wall; but, 
when lying on her back, the uterus falls backward and rests upon the 
vertebral column. Figs. 181, a and b, represent the same woman in the 
upright and horizontal positions respectively, and give a good idea of 
the changes in contour of the abdomen. 

As the uterus grows out of the pelvic cavity, it usually becomes 
slightly twisted to the right, so that its left margin is directed more 
anteriorly than the right. Occasionally the torsion may be in the oppo¬ 
site direction, statistics showing that it occurs to the right in 80 per 
cent, and to the left in 20 per cent, of the cases. The torsion is due in 
great part to the presence of the rectum, which occupies the left side 
of the pelvis; though occasionally the condition may represent merely 
an exaggeration of the original position of the non-pregnant uterus, 
which, as is well known, is not always perfectly symmetrical. 


TUBES AND OVARIES 

As has already been mentioned, the tubes and ovaries undergo 
marked changes in position with the advance of pregnancy, so that 
instead of extending outward almost at right angles from the cornua, 
their long axes become nearly parallel to the margins of the uterus. 
Occasionally, as the result of the upward traction exerted by the en¬ 
larging uterus, the ovaries become greatly elongated. More important, 
however, is their increase in vascularity, to which the large size of the 
corpus luteum of pregnancy is in great part due. It is generally be¬ 
lieved that ovulation ceases during pregnancy, so that new follicles do 
not ripen, and, accordingly, only the single large corpus luteum of 
pregnancy can be found in one of the ovaries. Seitz, Keller, Aschner, 
and others have shown that while typical ovulation does not occur, many 
follicles begin to grow and, after reaching a certain stage of develop¬ 
ment, undergo atretic changes, associated witl a marked development 



VAGINA 


189 


of lutein cells in the theca folliculi. In many instances these cells 
occupy the greater part of the interior of the ovary, and present a 
characteristic and striking appearance, but disappear soon after delivery. 
In such circumstances, they are designated by many writers as the “in¬ 
terstitial gland”; and, after once seeing them, it is difficult to escape 
the conclusion that they must have some specific internal secretory func¬ 
tion. Fellner states that the lipoids derived from them cause uterine 
hypertrophy when injected into experimental animals. 

It is generally stated that the muscular fibers of the tubes undergo 
considerable hypertrophy under the influence of pregnancy, but I believe 
that Mandl is correct in stating that, if it occurs at all, it is very 
slight in extent. Occasionally, in uterine pregnancy, decidual cells may 
develop in the stroma of the tubal mucosa, but they never lead to the 
formation of a continuous membrane, as in the uterus. Such observa¬ 
tions are of extreme rarity, but I have made them in several instances. 


VAGINA 

Increased vascularity is the most marked change in the vagina, and 
to it are due the more copious secretion and the characteristic violet 
coloration of pregnancy. At the same time there is considerable hyper¬ 
trophy of the elements composing the vaginal walls, the latter not in¬ 
frequently increasing in length to such an extent that the lower portion 
of the anterior wall protrudes slightly through the vulval opening. The 
papillae of the vaginal mucosa also undergo considerable hypertrophy, 
whence results an increased roughness of the membrane, which some¬ 
times feels almost like a calf’s tongue. 

The vaginal secretion is considerably augmented, and normally is 
represented by a thick, white, crumbly substance, somewhat like cottage 
cheese, which possesses a distinctly acid reaction. Doderlein showed 
that it consists of epithelial cells and a large number of long, tolerably 
thin bacilli, but that under normal conditions it does not contain 
leukocytes or pathogenic microorganisms. Zweifel showed that the acid 
reaction is due to the presence of lactic acid, which he believes plays a 
marked part ’in preventing the growth of pathogenic bacteria. Griifen- 
burg has shown that the degree of acidity \aiies "with the phase of the 
sexual cycle, the titer being lowest at the peiiod of ovulation and high¬ 
est during pregnancy. 

Whether the cellular contents of the vaginal secretion undergo 
cyclical changes analogous to those observed by Long and Evans in the 
rat, and by other observers in various experimental animals, is not 
known, but the subject offers an interesting field for research. 

The increased vascularity attending pregnancy is not confined to the 
genitalia, but extends to the various organs in their vicinity, and as a 
consequence there is a slight relaxation of the various pelvic joints, 
which is accompanied by an increase in their motility, as vas con¬ 
clusively shown by Bud in. 


190 


CHANGES IN THE MATERNAL ORGANISM 


ABDOMINAL WALLS 

With the enlargement of the uterus the skin covering the anterior 
abdominal walls and the adjoining portions of the thighs is subjected 
to considerable tension, which, according to Zeiler, results in the rupture 
of the elastic fibers of the reticular stratum of the cutis, and the forma¬ 
tion of depressed areas which are known as the striae of pregnancy. 
In primiparae these present a pinkish or slightly bluish appearance, 



Fig. 182 .—Abdomen of Primipara at Term, showing Striae. 


as is well illustrated in Fig. 182, whereas in multiparae two varieties are 
observed, some resembling those of primiparous women, while others 
present a glistening silvery appearance, the former resulting from the 
present condition, and the latter representing cicatrices from previous 
pregnancies. 

The formation of striae is not characteristic of pregnancy, as it is 
lacking, according to Taussig, in about 22 per cent, of the cases and is 
frequently observed in non-pregnant women and occasionally in men, in 
whom there has been a rapid increase in the size of the abdomen, either 
from the presence of a tumor or ascites, or the rapid development of 
fat. They occur less frequently in women of the upper classes, and can 
be prevented to some extent by massaging the abdomen with some oleagi- 












BREASTS 


191 


nous substance and by the use of a properly fitting corset or abdominal 
support. 

Not infrequently the abdominal walls are unable to withstand the 
tension to which they are subjected, and the recti muscles become sep¬ 
arated in the middle line, giving rise to a diastasis of greater or less 
extent. Where the process is exaggerated, a considerable portion of 
the anterior wall of the uterus is covered by nothing beyond a thin layer 
of tissue consisting only of skin, fascia, and peritoneum. In rare in¬ 
stances the separation is sufficiently extensive to admit of a hernial pro¬ 
trusion of the gravid uterus. 


BREASTS 


Under the influence of pregnancy marked changes occur in the 
breasts, and in the early weeks the woman not infrequently complains 
of a sense of tenseness and pricking in these regions. After the second 
month the breasts begin to increase in size and offer a somewhat nodular 
sensation on palpation, which is due to the hypertrophy of the mammary 
alveoli, and as they become still larger a delicate tracery of bluish veins 
appears just beneath the skin. Even more characteristic, however, 
are the changes occurring in the nipples and the tissues in their 
vicinity. The nipples themselves soon become considerably larger, more 
deeply pigmented, and more erectile, and after the first few months a 
thin, yellowish fluid— colostrum —may be expressed from them by gentle 
massage. At the same time the areola surrounding the nipple becomes 
considerably broader and much more deeply pigmented, the degree of 
pigmentation varying according to the complexion of the individual. In 
blondes the areolae and nipples assume a pinkish appearance, while in 
brunettes they become dark brown and occasionally almost black. ScaU 
tered through the areola are a number of small roundish elevations, the 
so-called glands of Montgomery , which result from the hypertrophy of 
the sebaceous glands. In a small number of cases similar structures 
make their appearance in a less deeply pigmented area outside of the 
periphery of the areola, and which is designated as the secondary areola. 
If the increase in the size of the breasts be very marked, the skin 
frequently presents striations similar to those observed in the abdomen. 

Formerly it was believed that direct nervous connection existed be¬ 
tween the uterus and the breasts, but the demonstration that lactation 
can be established after excluding the spinal nervous mechanism by 
severing all nerves supplying the breast, or even after transplanting the 
organ to other portions of the body, clearly indicates that some other 
factor must be invoked in explanation of the mammary changes in preg¬ 
nancy. Starling and Lane Claypon in 1906 stated that they were able 
to produce definite hypertrophy of the breasts of virginal rabbits by the 
injection of extracts obtained from the bodies of foetal rabbits, and 
attributed the result to certain specific hormones. Their conclusions 
were generally accepted until 1911, when Frank and Unger stated that 
they were unable to confirm them and attributed them to faulty observa- 




192 


CHANGES IN THE MATERNAL ORGANISM 


tion and technic. However that may be, there is no doubt that the 
mammary changes characteristic of pregnancy must be due to the action 
of specific substances circulating in the blood, as was demonstrated by 
the observations of Schauta and of Basch upon the Blazek sisters. In 
this instance, one of the pygopagous twins gave birth to a child, which 
could be suckled equally well by its own mother or by its nulliparous 
aunt. 


CHANGES IN THE REST OF THE BODY 

As has already been indicated, the changes resulting from pregnancy 
involve nearly every portion of the body, and in many cases the general 
condition of the patient differs markedly from what it was before con¬ 
ception. Many women suffer numerous inconveniences, while others 
enjoy better health than at any other time. 

Heart. —Owing to the upward pressure upon the diaphragm, the 
heart becomes displaced in such a way that its area of dullness undergoes 
a considerable increase in size. Basing his opinion upon this fact, 
Larcher in 1827 promulgated the doctrine that considerable cardiac 
hypertrophy was a constant concomitant of pregnancy. His views ob¬ 
tained rapid acceptance in France, but were received with skepticism 
in Germany. On the other hand, the researches of Dreysel indicate that 
hypertrophy does take place, as he found that the hearts of 76 pregnant 
and puerperal women weighed 8.8. per cent, more than those of non¬ 
pregnant individuals. The question, however, cannot be regarded as 
definitely settled, and offers an attractive field for future work. 

If the total quantity of blood is not increased during pregnancy, and 
even more so if it is, it would seem that the demands of the enlarging 
uterus and its contents could be satisfied only by a more rapid cir¬ 
culation of the blood. As the pulse rate is not materially in increased 
during pregnancy, it appears justifiable to conclude that such a result 
is accomplished by the heart expelling an increased amount of blood 
at each beat, which inevitably necessitates increased work, with coincident 
hypertrophy. 

The investigations of Slemons and Goldsborough in my service upon 
the blood pressure confirm such a view; as they were able by means of 
Erlanger’s sphygmomanometer to demonstrate a considerable increase 
in the pulse pressure, as well as in the “index” of the work of the heart. 
This was most marked in the later months of pregnancy and disap¬ 
peared during the puerperium; consequently, as the more extensive ob¬ 
servations of Jaschke in 1911 led to similar results, it seems reasonable 
to believe that the heart undergoes a certain amount of hypertrophy. 

Blood. —In former times it was generally believed that the changes 
incident to the placental circulation demanded an increase in the amount 
of maternal blood, and all the earlier writers stated that under the influ¬ 
ence of pregnancy an increased hydremia and a diminution in hemo¬ 
globin and red corpuscles took place, while at the same time an abnormal 
amount of fibrin could be noted. These observations were based upon 
antiquated methods of research, and it was not until 1886 that Fehling. 


CHANGES IN THE REST OF THE BODY 


193 


by the aid of modern appliances for examining the blood, came to the 
conclusion that it underwent little if any change. 

Since then a number of articles have appeared upon the subject, 
notably those of Wild, Zangemeister, Payer, and Dietrich. These investi¬ 
gations show that in the later months of pregnancy the amount of hemo¬ 
globin and of red corpuscles is normal, or even slightly increased, while 
there is a slight increase in the number of white cells. The leukocytosis 
is markedly accentuated at the time of labor, but falls rapidly in the 
puerperium unless infection supervenes. 

Observations made in my clinic in 1915 by Miller, Keith and Roun¬ 
tree upon the plasma and blood volume in pregnancy seem to show that 
there is a definite increase in both factors, which disappears during the 
puerperium. These conclusions were based upon the injection of known 
quantities of “vital red” into the circulation, and the colorimetric com¬ 
parison of the patients’ serum with standard preparations of serum 
colored with the same dye. More extended, but as yet unpublished, 
observations by Harris in our service during 1922 and 1923, reenforce 
such conclusions, and demonstrate that the volume of blood is definitely 
increased, while the cell and hemoglobin content is relatively, but not 
actually, diminished. Moreover, the demonstration by Dienst of a change 
in the relative proportions of the several protein constituents of the blood 
plasma during pregnancy points in the same direction. 

The specific gravity of the blood is somewhat lowered, and Zange¬ 
meister and Landsberg demonstrated a diminished freezing point and a 
decrease in its albuminous content; while Zangemeister and Payer noted 
a decrease in the alkalinity of the blood during pregnancy, but its exact 
significance is not let clear. 

In all probability the blood also contains various substances which are 
not present at other times, but our information upon the subject is as 
yet very vague. In this connection it suffices to note that Grafenburg, 
Clowes and Goldsborough and Ecalle have demonstrated a definite in¬ 
crease in the antitryptic ferment content, and Chauffard, Laroche, 
Grigand, Huffmann, and Ecalle a striking increase in the cholesterin 
content, which has been confirmed by Slemons and Stander who have 
shown that the lipoid content of the blood is greatly augmented during 
pregnancy, and are inclined to regard it as a preliminary provision for 
lactation. Furthermore, Heynemann and Ecalle state that there is a 
marked difference between the serum of pregnant and non-pregnant 
women, in that the former after heating will induce hemolysis of 
washed horses’ corpuscles in the presence of cobra poisoning, whereas the 
latter will not. It was formerly believed that the adrenalin content of 
the blood was increased during pregnancy, but Neu has demonstrated 
that such is not the case. He has, however, shown the presence of a 
pressor substance in the serum, but not in the plasma, which he believes 
is histamin, which has originated during the changes connected with the 

coagulation of the blood. 

Respiratory Tract.— According to Siegmund, Koblanck, and others, 
more or less characteristic changes may occur in the nasal mucosa. 
These consist in reddening and thickening of the so-called Fliess’ areas, 



194 


CHANGES IN THE MATERNAL ORGANISM 


and it is stated that at the time of labor the character of the uterine 
contractions may be altered by intranasal manipulations. 

It has long been known that pregnancy may exert a deleterious in¬ 
fluence upon the voice of singers, and Hofbauer has shown that it is 
associated with changes in the larynx which occur in three-quarters of 
all pregnant women. These consist in reddening and edema of the false 
vocal cords, as well as of the interarytenoid region. In addition to the 
usual histological manifestations of inflammation, decidua-like cells make 
their appearance in the submucosa. 

Owing to the upward displacement of the diaphragm in the later 
months of pregnancy, it would seem as though the capacity of the lungs 
would be decreased. Nevertheless, Dohrn has shown that such is not the 
case, since the diminished height of the pleural cavities is compensated 
for by an increase in width. Furthermore, the investigations of Zuntz 
and myself upon the respiratory exchange show that, while there is 
no great increase in the consumption of oxygen or in the output of 
carbon dioxid, there is nevertheless a great increase in the amount of 
air inspired. 

Digestive Tract. —In many instances the early months of pregnancy 
are complicated by minor disorders of digestion. Frequently these are 
not independent affections, but are to be regarded as a manifestation of 
a mild toxemia. 

At least one-half of all pregnant women suffer from constipation. 
In the later months of pregnancy this may be regarded as being partly 
due to the pressure of the enlarged uterus, and partly to the loss of 
tonicity of the abdominal walls resulting from their distention. 

During pregnancy the liver is in a state of unstable equilibrium, and 
is readily affected by various conditions, as is demonstrated by the lesions 
accompanying eclampsia, vomiting of pregnancy, and acute yellow 
atrophy of the liver, which will be discussed in detail in the chapter on 
the toxemias of pregnancy. 

Hofbauer considers that even in normal pregnancy the liver presents 
characteristic changes, so that one is justified in speaking of the “liver 
of pregnancy.” The changes consist in the appearance of fat in the cells 
occupying the central portion of the lobules, the disappearance of glyco¬ 
gen, and the dilatation of the biliary channels, the central veins, and 
the afferent capillaries. Opitz has cast grave doubt upon these state¬ 
ments, but should such changes occur as regular concomitants of preg¬ 
nancy, they would offer a satisfactory explanation for several of the 
alterations in metabolism which characterize the condition. 

Urinary Tract. —The kidneys are likewise under a considerably in¬ 
creased strain during pregnancy, and slight degrees of parenchymatous 
change are so common that they are assigned by the Germans to the 
“kidney of pregnancy.” Such conditions are usually connected with the 
various disturbances of metabolism associated with the toxemias of preg¬ 
nancy and will be considered under that heading, while various altera¬ 
tions in the constitution of the urine in normal pregnancy will be taken 
up in the section on general metabolism. 

The ureters are sometimes compressed by the growing uterus, and 



CHANGES IN THE REST OF THE BODY 


195 


under such conditions a mild infectious process, which otherwise might 
not give rise to symptoms, may eventuate in a pyelitis or pyelo- 
nephrosis. 

In the early months the bladder is more or less compressed by the 
growing uterus, and consequently increased frequency of micturition is 
often noted. As the uterus rises up into the abdominal cavity it carries 
with it the bladder, which then becomes an abdominal rather than a 
pelvic organ. Corresponding to the torsion of the uterus about its 
vertical axis, the bladder is pushed to the right side of the abdomen in 
possibly 90 per cent, of all pregnant women. 

Ductless Glands.—With the great increase in our knowledge con¬ 
cerning the functions and correlations of the endocrin glands it has 
gradually become recognized that all of them exert directly or indirectly 
a stimulating or retarding effect upon the sexual processes in women, 
which may become greatly exaggerated during pregnancy. Our still 
somewhat fragmentary knowledge upon the subject w^as well summarized 
by Blair Bell, and particularly by Seitz in his exhaustive report to the 
German Gynecological Congress in 1913, to which the reader is referred 
for detailed information. Lange in 1899 reported that he found the 
thyroid gland definitely hypertrophied in 108 out of 133 wvunen during 
the last three months of pregnancy. As albuminuria was present in 18 
of the women in whom no hypertrophy was noted, he naturally thought 
that there might be some direct relation between its absence and the 
urinary changes. With this in mind, he administered iodothyrin to a 
number of albuminuric pregnant women, and in some instances noted a 
rapid disappearance of the albumin. His views were promptly taken 
up by Nicholson and others, and made the basis for a theory concerning 
the origin of the toxemias of pregnancy. As will be indicated in the 
appropriate chapter, the theory rests upon very unstable foundations, 
and has in great part been abandoned. 

With the exception of von Graff, it is now generally believed that 
a moderate degree of hypertrophy of the thyroid is a usual concomitant 
of normal pregnancy, and may be recognized clinically in 65 to 90 per 
cent, of all cases. Its significance is not clear, but that the thyroid plays 
an important part in pregnancy was shown by the experiments of Halsted 
and Ukita. The former found that when the gland was partially re¬ 
moved from pregnant dogs, puppies were born whose thyroids v ere 
many times the normal size, thereby indicating that they had hyper¬ 
trophied in order to supplement the deficient maternal secretion. The 
latter states that the removal of the gland from pregnant rabbits led 
to a great prolongation of the duration of pregnancy, and to the birth 
of undersized and poorly developed offspring, whose thyroids were defi¬ 
nitely hypertrophied and showed definite signs of increased secretory 

activity. 

It 'is likewise generally admitted that the parathyroids undergo a 
considerable hypertrophy during pregnancy, and that their secretion is 
essential to its normal progress. To a great extent they act throug 
the calcium metabolism. Insufficiency of the parathyroid secretion fre- 




196 


CHANGES IN THE MATERNAL ORGANISM 


quently manifests itself by the development of tetany in the mother, 
as will be described in the appropriate place. 

As the thymus gland ordinarily atrophies with the approach of 
puberty it would not appear to exert any influence upon pregnancy. 
Bompiani, however, has shown that in cases of abnormal persistence of 
the organ it undergoes diminution in size during pregnancy, to enlarge 
again after delivery. Theoretically, it is possible that the presence of 
a persistent thymus may have important effects upon the entire genera¬ 
tive process. 

Since Launois and Mulon, in 1904, directed attention to an hyper¬ 
trophy of the hypophysis during pregnancy, a great deal of work has 
been done upon the subject, and the investigations of Eisemann and 
Stumme, Cushing, Mayer, and others have definitely shown that the 
anterior lobe of the gland regularly undergoes great hypertrophy during 
pregnancy, and returns to the usual size after its completion. The 
hypertrophy, which may double the size of the lobe, is due in great part 
to a marked increase in the number and size of the “HauptzellenT Its 
significance is not yet clear, but it has been suggested that the hypo¬ 
physeal secretion may supplement a supposed deficiency in that derived 
from the ovaries. Wallis and Bose suggest that the well recognized 
intolerance of pregnant women for sugar, as well as the occasional 
occurrence of transient glycosuria may be attributed to excessive func¬ 
tioning of the hypertrophied organ. Furthermore, on account of the 
known relation existing between abnormalities of the hypophysis and 
the development of acromegaly, a similar origin has been suggested for 
the non-edematous thickening of the features, as well as of the extremi¬ 
ties, which is observed in so many pregnant women. 

The posterior or infundibular portion of the hypophysis does not 
hypertrophy during pregnancy, but, in addition to its effect upon the 
blood pressure, it possesses the power of markedly stimulating uterine 
contractions, as has been shown by Dale, Bell, and others. Whether it 
is normally concerned in the regulation of uterine contractions at the 
time of labor is not known, but from it has been isolated a substance 
which is closely related to imidazolylethvlamin, which, as is well known, 
is one of the constituents of ergot. Extracts of the posterior lobe are 
now marketed under various names, such as pituitrin and hypophysin, 
and are extensively used in obstetrical practice to stimulate inefficient 
uterine contractions. 

It is also definitely known that the cortex of the suprarenal bodies 
undergo definite hypertrophy during pregnancy, which, according to 
Kolde, is most marked in the zona fasiculata. Aschner, who has con¬ 
sidered the question in detail, emphasizes the great increase in the lipoid 
content of the gland, and suggests that it may be the source of the 
greatly increased content of such substances in the blood of pregnant 
women. 

Skeleton and Teeth.—Rokitansky described the formation of irregu¬ 
larly shaped placques of porous, newly formed bone, or osteoid tissue, 
upon the internal surface of the cranial hones during pregnancv. These 
he designated as puerperal osteophytes, but neither he nor the subsequent 







CHANGES IN THE REST OF THE BODY 


197 


observers, who have confirmed his findings, are clear as to their signifi¬ 
cance. Dreyfuss states that their existence may be demonstrated by 
the use of the X-ray in every third pregnant woman, and is inclined to 
believe that their production is in some way associated with the activity 
of the pituitary body. 

Hanau considers that they are most pronounced when an excessive 
formation of osteoid tissue occurs in other parts of the body. This he 
is inclined to attribute to a slight grade of osteomalacia, which he and 
Gelpke regard as physiological in all pregnancies, and associated with 
the supply of calcium salts to the foetus. Dibbelt estimates that through¬ 
out the second half of pregnancy at least 0.17 gram of calcium oxid must 
be supplied to the foetus each day, while Bar, and Givens and Macy 
calculate that during the last two months the quantity must be increased 
to 0.64 or 0.70 gram per day. It is therefore evident, unless the pregnant 
woman assimilates an unusual amount of calcium from her food, that 
the foetus must be supplied from her own body, and this is usually 
effected by partial decalcification of the bones and teeth. For that 
reason the teeth are prone to decay rapidly, so that the expression “for 
every child a tooth” has become proverbial. As a pint of milk contains 
0.5 gram of calcium, it is apparent that the ingestion of a quart each 
day will more than cover the need for calcium, and will likewise serve 
as an efficient prophylactic. 

Owing to the increased vascularity, the various pelvic joints become 
more succulent and permit greater mobility. Occasionally they become 
so relaxed that locomotion is seriously interfered with. The treatment 
of this abnormality will be considered in the chapter upon the pathology 
of pregnancy. 

Nervous System. —Various disturbances of the nervous system occur 
during pregnancy, but as they are distinctly abnormal they will be con¬ 
sidered later. On the other hand, mild degrees of disturbed mental equi¬ 
librium are so frequently observed as to be considered almost physio¬ 
logical. In this category may be placed the longings and cravings 
for unusual or abnormal articles of diet. Many women also experience 
pronounced changes in disposition, and not a few multiparous patients 
recognize the occurrence of pregnancy by their appearance. Again, in 
those of neuropathic tendencies the mental equilibrium may be over¬ 
thrown to a greater or less degree, the patient becoming excitable, mor¬ 
bid, or morose, and in rare instances developing a true psychosis. 

Skin.— Reference has already been made to the formation of striae 
and to the pigmentation of the nipple and areola. In other cases the 
linea alba becomes markedly pigmented. Occasionally irregularly 
shaped, yellowish patches of varying size appear on the face and neck, 
the condition being known as cloasma, which fortunately usually dis¬ 
appears after delivery. Very little is known concerning the nature of 
those conditions, but Wychgel has demonstrated that the pigment de¬ 
posited in the papillary layer of the skin responds to the usual tests for 
iron. He considers that it is derived from the hemoglobin of the ma¬ 
ternal blood cells which have succumbed in the fight against the foetal 

tissues. 


198 


CHANGES IN THE MATERNAL ORGANISM 


General Metabolism. —Generally speaking, gestation is characterized 
by improved health. In some instances the improvement in nutrition 
is noted shortly after conception, but it may not become manifest for 
several months. For this reason it is frequently possible to distinguish 
two periods in pregnancy. The earlier is characterized by lassitude, 
mental depression, and some loss of weight, while the latter is conspicu¬ 
ous for an excellent condition of body and mind. 

Analogous conditions have been observed in pregnant dogs, rabbits, 
and guinea-pigs by Hagemann, Yer Eecke, Jageroos, Bar, and Murlin. 
Those interested in the subject are referred particularly to the monu¬ 
mental mentabolic studies of Bar, which clearly show that in animals 
catabolic processes are most prominent in the first half of pregnancy, 
as is indicated by the fact that more material is excreted than ingested, 
whereas the reverse obtains in the second half. During the latter 
period there is a marked tendency toward storage of the various food 
stuffs. As was shown by Bar in pregnant dogs, this storage, particularly 
of proteids, is more than sufficient for the needs of the foetuses and their 
appendages, so that in the healthy animal the second half of pregnancy 
may be regarded as a period of gain, and not as a sacrifice of the 
individul for the sake of the species. 

Metabolic studies show that women in the weeks immediately pre¬ 
ceding delivery possess an unusual capacity for storing up the essential 
elements of their diet, and that their metabolism is analogous to that 
observed in animals in the corresponding period of pregnancy. In 1862 
Gassner studied the changes in weight during the last three months, 
and found an average monthly increase of from 3% to 5% pounds. 
The gain was proportional to the weight of the individual, and was 
relatively larger in multigravidae. Moreover, he considered that the 
absence of such a gain in weight was indicative of the death of the 
foetus in utero. Confirmatory results were obtained by Zangemeister in 
1916, who found that a daily increase averaging 55 grams occurs 
during the last months of pregnancy. Moreover, he noted that the gain 
continues until three or four days before the onset of labor, after which 
a loss of 1,000 grams in weight occurs. Accordingly, if normal patients 
are weighed daily before breakfast, the imminence of labor may he pre¬ 
dicted whenever the usual gain is replaced by a loss in weight. On 
the other hand, he showed that an excessive gain in weight is abnormal, 
and in many instances enables one to detect the presence of occult 
edema, before visible swelling and pitting of the skin occur. 

The daily output of urine is subject to so many variations, being in¬ 
fluenced by climatic, dietetic, and individual peculiarities, that it is 
difficult to fix a normal standard. Ordinarily, it varies between 1,000 
and 1,500 c. c., though smaller or larger amounts may be excreted without 
necessarily indicating a pathological condition. Of particular interest, 
though, is the ratio which the volume of the urine bears to the fluid in¬ 
take. In three normal pregnancies my former associate, J. M. Slemons, 
found that during the days immediately preceding delivery it represented 
from one-half to three-quarters of the fluid taken by the mouth, whereas 







CHANGES IN THE REST OF THE BODY 


199 


in a patient with dead twins it amounted to 93 per cent., which is ap¬ 
proximately the normal non-pregnant ratio. 

Proteid metabolism in the later months of pregnancy has been 
studied by Zacharjewsky, Schrader, Hahl, Hoffstrom, Iioogenhuyse, as 
well as in my clinic, and shows that considerable quantities of nitrogen 
are retained when the woman is allowed an adequate diet. The average 
daily nitrogeneous exchange in three women studied by Slemons is 
given in the accompanying table. 


Type 

Fluid 

Ingested. 

Quantity 
of Urine. 

Nitrogen 
in Food. 

Nitrogen 
in Urine. 

Nitrogen 
in Faeces. 

Nitrogen 

Balance. 

Primigravida.. . 
Multigravida... 
Twin Pregnancy 

1,780 c. c. 
1,890 c. c. 
2,354 c. c. 

1,306 C. C. 
1,007 c. c. 
1,135 c.c. 

13.80 gms. 
16.77 gms. 
15.00 gms. 

12.43 gms. 
13.26 gms. 
8.28 gms. 

0.95 gm. 
0.53 gm. 

2.00 gms. 

+0.42 

+2.98 

+4.72 


Such a storage of nitrogen as shown by these figures would indicate 
a considerable construction of proteid tissue, and corresponds to the 
growth of the foetus, placenta, uterus, and the maternal organism in 
general. 

As to the period of pregnancy at which the maternal organism first 
acquires the power of storing nitrogen, it is impossible to make definite 
statements. In one of my patients, studied by Karl M. Wilson, daily 
observations upon the nitrogen exchange from the tenth to the four¬ 
teenth week of pregnancy, revealed a considerable capacity for storing 
nitrogen, and even at that early period the total storage for the four 
weeks amounted to 59.99 grams. As it is evident that this amount was 
greatly in excess of the needs of the developing ovum, it must be assumed 
that the bulk of it was added to the general maternal organism, possibly 
as a reserve to be drawn upon later, when the needs of the embryo be¬ 
come greater. 

In a patient studied by Hoffstrom for the last twenty-four weeks 
of pregnancy, storage of nitrogen was observed throughout the entire 
period. This averaged 1.84 grams per day, so that the total amount 
stored amounted to 310 grams ; the most marked storage occurring from 
the twenty-ninth week onward, when the needs of the grow ing foetus 
were at a maximum. He estimated that 101 grams of this amount veie 
needed for the development of the foetus, whereas the balance must 
have been added to the general maternal organism. He calculated that 
approximately 51 grams of this balance were utilized in the de\elopment 
of the uterus and breasts, leaving 158 grams to be added to the maternal 
nitrogen capital, although it was impossible to make a definite statement 

as to the exact manner in which it was stored. 

Furthermore, similar results were obtained in two patients studied 
in my clinic in 1915 by Wilson during the last nineteen and fifteen 
weeks of their respective pregnancies. Both were found to lx* storing 
nitrogen throughout the entire period, and in both the storage was 
far in excess of the actual needs of the developing foetus. As the first 
patient stored 419.38 grams, and the latter 336.21 grams of nitrogen, 




















200 


CHANGES IN THE MATERNAL ORGANISM 


and as the total nitrogen of the child was 79.95 and 78.91 grams re¬ 
spectively, it is apparent that large amounts of nitrogen were added to 
the general maternal organism. It would therefore appear that in 
healthy women the ability to store nitrogen is acquired at a comparatively 
early period of pregnancy, and possibly at its very inception. Moreover, 
this capacity for storage increases as pregnancy advances and as the needs 
of the foetus become greater. As the amount stored is far in excess 
of the needs of the foetus, a considerable quantity of “reserve” nitrogen 
must be added to the maternal organism, which can be drawn upon, and 
possibly entirely exhausted, during labor and the puerperium. 

In patients suffering from gastrointestinal disturbances, which so 
frequently accompany early pregnancy, it is probable that storage of 
nitrogen does not begin until the symptoms have subsided; at it is 
frequently noted that such patients lose considerably in weight during 
the continuance of the attack. In general, however, it may be assumed 
that pregnancy is not necessarily a period of sacrifice on the part of 
the individual, but may actually be one of gain. 

It might be assumed that the nitrogenous content of the urine is 
increased during pregnancy on account of the fact that it contains the 
waste products of both the foetal and maternal metabolism. Such a 
belief, however, is erroneous, at least in the latter months of pregnancy, 
as the nitrogen storage to which we have just referred must necessarily 
be accompanied by a decrease in the urinary nitrogen. 

Along with the quantitative change in the elimination of nitrogen are 
associated certain qualitative variations. Thus, the urea content is rela¬ 
tively low, and represents only 80 to 85 per cent, of the total nitrogen, 
instead of 85 to 90 per cent, as in non-pregnant individuals. At the 
same time there occurs a slight rise in the percentage of ammonia, which 
is still further accentuated in twin pregnancy. Furthermore, there is 
usually an increase in the percentage of undetermined nitrogen, a part 
of which, according to Falk and Hesky, is accounted for by an increased 
elimination of amino acids and peptid nitrogen. In our experience, 
these increases are relative rather than absolute; for, while the per¬ 
centage is greater than in non-pregnant women, the lessened total 
nitrogen output will result in the elimination of but little more of these 
substances than in the non-pregnant condition. Zaeharjewsky found that 
the uric acid excretion was practically normal. Chemical examination 
of the blood leads to similar conclusions, and, since the appearance of 
Folin’s contribution in 1917, it has been generally admitted that the 
non-protein nitrogen content of the blood is diminished rather than 
increased; while the content in urea is relatively decreased, as one would 
expect from the low urinary findings. 

In animal experiments of Hagemann, Jageroos, Harnack and Klein, 
and Bar, study of the mineral metabolism revealed changes analogous 
to those observed in the nitrogenous elimination, and indicated a reten¬ 
tion of various inorganic substances. The investigations of Schrader, 
Boni, Hoffstrom, Zangemeister, and others, in women show a similar 
retention, whose object is to supply the calcium, phosphorus, sulphur, 
chlorin, etc., essential to the upbuilding of the foetus. That the median- 


CHANGES IN THE REST OF THE BODY 


201 


ism is not always perfect has already been indicated in connection with 
the calcium metabolism, when it was stated, if sufficient quantities of 
calcium were not obtained from the food, that deficit would be made good 
by the decalcification of the bones and teeth of the mother. Fetzer 
showed in rabbits that the amount of iron contained in the fcetal tissues 
varies with the amount in the mother’s food, but that when this falls 
below an irreducible minimum the quantity necessary for the well-being 
of the foetus is abstracted from the maternal tissues. Following the 
delivery of the child or its death in utero, the various constituents in¬ 
volved soon show a tendency to return to the usual non-pregnant 
relations. 

Acetonuria was formerly considered a sign of foetal death, but more 
recent work shows that it is of no clinical significance. Stolz observed 
it in more than one-third of a series of 97 normal pregnancies, and 
Jageroos demonstrated it in nearly every normal labor. On the other 
hand, the appearance of the other acetone bodies—diacetic or oxybutyric 
acid—is always of pathological significance. 

The respiratory exchange has been studied in women by means of the 
Zuntz apparatus by Magnus-Levy, Zuntz, and myself. These investiga¬ 
tions show a considerable increase in the total quantity of air inspired, 
but indicate that the consumption of oxygen and the elimination of 
carbon dioxid is but little greater than would be expected on account 
of the increased weight of the pregnant woman. Baer, on the other hand, 
who has studied the basal metabolism in 44 pregnant women, concludes 
that in late pregnancy the metabolic rate is 33 to 35 per cent, above 
normal, but falls rapidly after delivery, so that on the third day post¬ 
partum it is increased by only 15 per cent., and falls to normal within 
the following week. 

Carpenter and Murlin in 1911 reported the results of their investi¬ 
gations upon the total energy metabolism of pregnant women by means 
of a modified Atwater Calorimeter in the Carnegie Nutrition Laboratory 
in Boston. They found “that the energy metabolism expressed per 
kilogram and hour is but little larger (4 per cent.) than for a woman in 
complete sexual rest.” Furthermore, they stated, while the energy 
metabolism of the newly born child was two and a half or three times 
as great per kilogram of weight as that of the mother, that the total 
energy metabolism of both mother and child during the first days of 
puerperium was not greater than before labor. 

The more we learn concerning the metabolism of normal pregnancy, 
the more are we impressed with the fact that the maternal organism in 
the second half of gestation preserves the strictest economy in its meta¬ 
bolic processes. Its purpose, of course, is to facilitate the upbuilding of 
the foetus without too great strain upon the mother, but we are as yet 
entirely ignorant of the mechanism by which such changes are rendered 
possible. 



202 


CHANGES IN THE MATERNAL ORGANISM 


LITERATURE 

Aschner. Dio Blutdriisenerkrankungen des Weibes, 1918. 

Bar. Legons de pathologie obstetricale. Paris, 1907. 

Baer. Basal Metabolism in Pregnancy and Puerperium. Trans. Amer. Gyn. Soc., 
1921, xlvi, 46-53. 

Basch. Ueber exp. Milchauslosung, etc. Deutsche med. Wochenschr., 1910, 
xxxvi, 981. 

Bayer. Zur physiol, u. path. Morphologie der Gebarmutter. Freund’s gyniikolo- 
gische Klinik, 1885, i, 369-662. 

Weitere Beitrage zur Lelirc voni unteren Uterinsegment. Beitrage zur 
Geb. u. Gyn., 1898, i, 167. 

Bell. The Pituitary Body. Brit. Med. J., 1909, Dec. 4. 

The Relation of the Internal Secretions to the Female Characteristics, etc. 
Proc. Roy. Soc. Med., Gyn. and Obst. Sect., 1914, vii, 47-76. 

Boivin et Duges. Traite pratique des maladies de 1’uterus, etc., 2me ed., Bruxelles, 
1834. 

Bompiani. Der Einfluss des Saugens auf die Restitutionsfahigkeit d. Thymus 
nach der Schwangerschaft. Zentralbt. f. allg. Path., 1915, xxv, Nr. 22. 

Budin. Des varices chez la femme enceinte. Paris, 1880. 

Carpenter and Murlin. Energy Metabolism of Mother and Child. Archives 
Int. Med., 1911, vii, 184-222. 

Chauffard, Laroche et Grigaud. Evolution de la cholesterinemie au cours de 
Uetat gravidique. L ’Obst., 1911, N. S. iv, 481-492. 

Clowes and Goldsborough. On the Antitryptic Reaction Exhibited m Preg¬ 
nancy. Proc. Soc. Exp. Biology and Med., 1913, x, 109. 

Cushing. Experimental Hypophysectomy. Bull. Johns Hopkins Hospital, May, 
1910. 

Deville. Quoted in extenso by Cazeaux, Traite de Part des accouchements, 3me 
ed, 1850, 107-111. 

Dibbelt. Die Bedeutung d. Kalksalze fiir d. Schwangerschafts- und Stillperiode. 
Ziegler's Beitrage, 1910, xlviii, 147-169. 

Dienst. Die Eiweissstoffe im Blutplasma unter normalen Verhaltnissen in der 
Schwangerschaft, etc. Archiv f. Gyn., 1918, cix, 669-702. 

Dietrich. Studien liber Blutveranderungen bei Schwangeren, etc. Archiv f. 
Gyn., 1911, xciv, 383-401. 

Doderlein. Das Scheidensekret, etc. Leipzig, 1892. 

Dohrn. Zur Kenntniss des Einflusses von Schwangerschaft, etc., auf die vitale 
Capacitat der Lungen. Monatsschr. f. Geburtskunde, 1866, xxviii, 457. 

Dreyfuss. Beitrage zur Frage der Osteophytenbildung in der Schwangerschaft. 
Archiv f. Gyn., 1922, cvx, 126-144. 

Dreysel. Ueber Herzhypertrophie bei Schwangeren und Wochnerinnen. D. I., 
Miinchen, 1891. 

Eisemann u. Stumme. Ueber die Schwangerschafts-verandernngen der Hypo- 
pliyse. Ziegler’s Beitrage, 1909, xlvi, 1-142. 

Falk u. Hesky. Ueber Ammoniak, Amino-sauern u. Peptid-stickstoff in Harne. 
Zeitschr. f. klin. Med., 1910, lxxi, 261-276. 

Fehling. Ueber Blutbescliaffenheit und Fruchtwassermenge bei Schwangeren, 
etc. Archiv f. Gyn., 1886, xxviii, 453. 

Fellner. Uber die Tatigkeit des Ovarium in der Schwangerschaft. Monatsschr. 
f. Geb. u. Gvn., 1921, liv, 88-95. 

Fetzer. Studien liber den Stoffhaushalt in der Graviditat. Zeitschr. f. Geb. u. 
Gyn., 1913, Ixxiv, 542-578. 




LITERATURE 


203 


Folin. Recent Biochemical Investigations in Blood and Urine. Jour. Am. Med. 
Assoc., 1917, ii, 1209-1218. 

Frank and Unger. An Experimental Study of the Changes Which Produce 
Growth of the Mammary Gland. Archives Int. Med., 1911, vii, 812-838. 

Frankenhauser. Die Nerven der Gebarmutter. Jena, 1867. 

Gassner. Ueber die Yeranderungen des Korpergewichtes bei Schwangeren. Mo- 
natsschr. f. Geburtskunde, 1862, xix, 1. 

Gelpke. Die Osteomalacie im Ergolzthale, Basel. 1891. 

Givens and Macy. The Ca and Mg content of the human foetus. J. Biol. Chem., 
1922, li, 34. 

Grafenberg. Die zyklischen Schwankungen des Sauretiters im Scheidensekret. 
Archiv f. Gyn., 1918, cviii, 628-656. 

Hagemann. Ueber Eiweissumsatz wahrend der Schwangerschaft. Archiv f. Anat. 
u. Physiol. Phys. Abtheil., 1890, lvi, 577. 

Haul. Beitrag zur Kenutniss des Stoffwechsels wahrend der Schwangerschaft. 
Archiv f. Gyn., 1905, lxxv, 31-48. 

Halban. Scliwangersreactionen der fotalen Organe, etc. Zeitschr. f. Geb. 
u. Gyn., 1904, liii, 191-231. 

Hanau. Ueber Knochenveranderungen in der Schwangerschaft, etc. Fortschritte 
d. Med., 1892, Nr. 7. 

IJelie. Recherehes sur la disposition des fibres musculaires de 1 ’uterus developpes 
par la grossesse. Paris, 1864. 

Henle. Eingeweidelehre, II. And., 476, 1873. 

Heynemann. Eine Reaction im Serum Schwangerer. Archiv f. Gyn., 1910, xc, 
236-254. 

Hofbauer. Die Graviditats-veranderungen. Volkmann's Samml. klin. Vortrage, 
1910, Nr. 586. 

Hoffmann. Morphologische Untersuchungen iiber die Muskulatur des Gebar- 
mutterkorpers. Zeitschr. f. Geb. u. Frauenkrankheiten, 1876, i, 448-473. 

Hoffstrom. Une experience sur les echanges nutritifs pen<lant la grossesse. 
L ’Obstetrique, 1910, N. S. 1060-1071. 

IIofmeier. Das untere Uterinsegment in anat. u. physiol. Bezielmng. Der schwan- 
gere und kreissende Uterus, Bonn, 1886, 21-74. 

Hoogenhuyse et Doeschate. Recherehes sur les echanges organiques chez les 
femmes enceintes. Annales de gyn. et d’obst., 1911, N. S. vii, 17-33. 

Huffmann. Zur Bestimmung des Gesammtscholesterins im Blute, etc. Zentralbl. 
f. Gyn., 1915, 33-40. 

Hunter. The Anatomy of the Gravid Uterus, 1774. 

Jageroos. Studien iiber den Eiweiss-Phosphor- u. Salzumsatz wahrend der Gravidi- 
tat. Archiv f. Gyn., 1902, lxvii, 517. 

Ueber die Aceton-korper des Harnes, etc. Archiv f. Gyn., 1911, xciv, 656-663. 

Jasciike. Blutdruck und Herzarbeit in der Schwangerschaft, etc. Archiv f. 
Gyn., 1911, xciii, 809-832. 

Joessel und Waldeyer. Das Becken. Bonn, 1899, 781. 

Keller. Ueber Veranderungen am Follikelapparat des Ovariums wahrend der 
Schwangerschaft. Beitriige zur Geb. u. Gyn., 1913, xix, 13-38. 

Krause. Quoted by Spiegelberg-Wiener, Lehrbuch der Geburtshiilfe, III. Aufl., 
1891, 53. 

Landsberg. Untersuchungen iiber den Gehalt des Blutplasmas an Gesammtei- 
weiss. Archiv f. Gyn., 1910, xcii, 693-720. 

Lange. Die Beziehungen der Schilddriise zur Schwangerschaft. Zeitschr. 1. Geb. 
u. Gyn., 1899, xl, 36-72. 

Larcher. Quoted from Ribemont-Dcssaignes and Lepage, Precis d’obstetrique. 
Paris, 1894. 


204 


CHANGES IN TIIE MATERNAL ORGANISM 


Launois et Mulon. Etude sur 1 ’liypophyse humaine a ia fin de la gestation. 

Annales de gyn. et d’obst. 2mc Ser., 1904, i, 2-13. 

Long and Evans. The Oest.rous Cycle in the Rat. Berkeley, 1922. 

Luschka. Die Anatomie des menschlichen Beckens. Tiibingen, 1864, 365. 
Magnus-Levy. von Noorden’s Handbuch dcr Pathologic des Stoffwechsels. 1906, 
408. 

Mayer. Ueber die Beziehungen zwischen Keimdriisse u. Hvpophyse. Archiv f. 
Gyn., 1910, xc, 600-625. 

Miller, Keith & Rowntree. Plasma and Blood Volume in Pregnancy. J. Am. 
Med. Assn., 1915, lxv, 779-782. 

Murlin. Nitrogen Balance during Pregnancy. Amer. J. Physiol., 1910, xxvii, 
177-205. 

Protein Metabolism of Normal Pregnancy. Surg. Gyn. & Obst., 1913, xvi, 
43-53. 

Neu. Zur Kritik der Frage: ‘ ‘ Adreningelialt ’ ’ des Blutes innerhalb der Gesta- 
tionszeit. Archiv f. Gyn., 1917, cvii, 35-44. 

Nicholson. Puerperal Eclampsia Treated by Large Doses of Thyroid Extract. 

Jour. Obst. & Gyn. Brit Emp., 1904, v, 32-37. 

Opitz. Ueber Leberveranderungen in der Schwangerschaft. Zeitschr. f. Geb. u. 
Gyn., 1913, lxxii, 351-361. 

Payer. Das Blut der Schwangeren. Archiv f. Gyn., 1904, lxxi, 421-459. 
Roederer. leones uteri humani. Gottingen, 1759. 

Rokitansky. Das Osteophyt. Lehrbuch d. path. Anat., III. Aufl., 1856, ii, 100. 
Ruge. Ueber die Contraction des Uterus in anat. u. klin. Beziehung. Zeitschr. f. 
Geb.u. Gyn., 1880, v, 149-157. 

Schauta. Die Pvgopagen-Schwestern Blazek. Gyn. Rundschau, 1910, iv, 437- 
445. 

Schrader. Einige abgrenzende Ergebnisse phys.-chemischen Untersuchungen iiber 
den Stoffwechsel wahrend der Schwangerschaft u. im Wochenbette. Archiv f. 
Gyn., 1900, lx, 534. 

Seitz. Die Follikelatresie wahrend der Schwangerschaft. Archiv f. Gyn., 1905, 
lxxvii, 203-356. 

Innere Sekretion u. Schwangerschaft. Leipzig, 1913. 

Sellheim. Die Geburt des Menschen. Deutsche Frauenheilkunde, 1913, i, 291. 
Siegmund. Head *s Felder u. weibl. Geschlechtsorgane. Zeitschr. f. Geb. u. Gyn., 
1908, lxii, 309-346. 

Slemons. Metabolism during Pregnancy, Labor, and the Puerperium. Johns 
Hopkins Hospital Reports, 1904, xiii, 111. 

Slemons and Goldsborough. The Obstetrical Significance of the Blood Pressures. 
Bull. Johns Hopkins Hospital, 1908. 

Slemons and Standee. The Lipoids of the Maternal and Fetal Blood at the 
Conclusion of Labor. Bull. Johns Hopkins Hospital, 1923, xxxiv, 7-10. 
Starling and Lane Claypon. Experimental Inquiry into the Factors Which 
Determine the Growth and Activity of the Mammary Gland. Proc. Roy. 
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Stolz. Die Aeetonurie in der Schwangerschaft, Geburt u. Wochenbette. Archiv 
f. Gyn., 1902, lxv, 531. 

Taussig. Factors in the Formation of Skin Striations During Pregnancv. Surg. 
Gyn. & Obst., 1913, 335-340. 

Ukita. Influence of Thyroidectomy on Gestation. Abstract J. Am Med Assoc 
1920, lxxiv, 213. 

Veit. Anatomie des schwangeren Uterus. Muller’s Handbuch der Geburtshiilfe 
1888, i, 193. ' 


LITERATURE 


205 


Ver Eecke. Les echanges materiels dans leurs rapports avec les phases de la vie 
sexuelle. Bruxelles, 1900. 

von Graff. Schilddriise u. Genitale. Archiv f. Gyn., 1914, cii, 109-140. 

Wallace and Bose. Glycosuria in Pregnancy. Jour. Obst. & Gyn. Brit. Emp., 
1922, xxix, 274-295. 

Wild. Untersuchungen liber den Hamoglobingehalt und die Anzahl der rothen 
und weissen Blutkorperchen bei Schwangeren und Woclmerinnen. Archiv f. 
Gyn., 1897, liii, 363-381. 

Wilson. Nitrogen Metabolism in Pregnancy. Bull. Johns Hopkins Hospital, 
1916, xxvii, 121-129. 

Wychgel. Untersuchungen liber das Pigment der Haut, etc. Zeitschr. f. Geb. u. 
Gyn., 1902, xlvii, 288-303. 

Zacharjewsky. Ueber den Stickstoffwechsel wahrend den letzten Tagen der 
Schwangerschaft, etc. Zeitschr. f. Biologic, 1894, xii, 368. 

Zangemeister. Die Beschaffenheit des Blutes in der Schwangerschaft und der 
Geburt. Zeitschr. f. Geb. u. Gyn., 1903, xlix, 92-103. 

Ueber die Auscheidung d. Chloride in d. Schwangerschaft. Archiv f. Gyn., 1908, 
lxxxiv, 825-836. 

Ueber das Korpergewicht Schwangerer. Zeitschr. f. Geb. u. Gyn., 1916, Ixviii, 
325-365. 

Zeiler. Zur Pathogenese der Delinungstreifen der Haut. Miinchener med. Wocli- 
enschr., 1905, iv, 1764-67. 

Zuntz. Respir. Stoffwechsel u. Athmung wahrend d. Graviditat. Archiv f. Gyn., 
1910, xc, 452-470. 

Zweifel. Die Scheideneinhalt Schwangerer. Archiv f. Gyn., 1908, lxxxvi, 564- 
601. 


CHAPTER VII 


DIAGNOSIS OF PREGNANCY—DURATION OF PREGNANCY—ESTIMA¬ 
TION OF DATE OF CONFINEMENT 

Ordinarily, the diagnosis of pregnancy offers little or no difficulty, 
and the patient is usually aware of the true condition before she consults 
a physician. In a small minority of cases, however, the task is by no 
means easy, and despite every known method at our command we are 
occasionally unable to decide with absolute certainty. 

Mistakes in diagnosis are most frequently made in the first few 
months, while the uterus is still a pelvic organ; although it is by no 
means impossible to confound a pregnancy, even at full term, with a 
tumor of some other nature. Such errors are usually the result of hasty 
or imperfect examination, but a false conclusion may sometimes be 
arrived at, even after the most conscientious exploration of the patient. 
Some idea of the frequency of such mistakes may be realized when it 
is stated that there is hardly a gynecologist of experience who has not 
opened the abdomen on one or more occasions, with the expectation of 
removing a tumor of the uterus or its appendages, and has been surprised 
to find himself in the presence of a normal pregnancy. 

It is often a matter of considerable importance that a diagnosis be 
made in the early months of pregnancy; but, unfortunately, it is just at 
this period that our diagnostic ability is most restricted, as the absolutely 
positive signs do not as a rule become available until the fifth month. 
Hence, it follows that in cases in which the existence of such a condition 
might affect the reputation or interests of the patient a positive expres¬ 
sion of opinion shoulu be deferred until the diagnosis is beyond all 
doubt. 

The diagnosis is based upon the presence of certain symptoms and 
signs. The former are chiefly subjective and are appreciated by the 
patient; while the latter are made out by the physician after a careful 
physical examination, in which the senses of sight, hearing, and touch, 
as well as certain laboratory procedures, are employed. 

The signs and symptoms are usually classified into three groups: the 
positive signs, which cannot usually be detected until after the fourth 
month; the probable signs, which can be appreciated at an earlier period; 
and the presumptive evidences, which are usually subjective in character, 
and may be experienced at varying periods. 

Positive Signs of Pregnancy.—These are four in number, and con¬ 
sist in (1) hearing and counting the foetal heartbeat, (2) ability to pal¬ 
pate the outlines of the foetus, (3) perception of its active and passive 
movements, and (4) recgonition of the foetal skeleton by means of the 
Roentgen ray; and when any one of them is obtained the diagnosis 
is established beyond all doubt. 


206 


POSITIVE SIGNS OF PREGNANCY 


207 


The Foetal Heart —Whenever one can hear and count the pulsations 
of the foetal hearty the diagnosis of pregnancy is assured beyond per- 
adventure; unfortunately, this sign cannot usually be appreciated until 
the eighteenthur twentieth week, though Sarwey and Benoist claim that 
it may be possible as early as the twelfth or fourteenth week. 

The foetal heart was first heard by Mayor, of Geneva, in 1818, but 
was recognized independently by Lejumeau de Kegaradec in 1821, to 
whom we are indebted for our fundamental information upon the sub¬ 
ject; indeed, so complete was his monograph that subsequent investiga¬ 
tions have revealed but little with which he was not familiar. Pie 
made his discovery quite accidentally, while attempting to hear the 
sounds which he supposed would be made by the foetus splashing in the 
liquor amnii. On auscultating the abdomen of a pregnant woman 
through her clothing, including the corset, he heard a double sound, 
which varied in frequency from 1P3 to 1P8 beats to the minute, and 
closely resembled the ticking of a watch under a pillow. Pie concluded 
that it could be produced only by the foetal heart, as the pulse of the 
mother did not exceed 70. P'or further details concerning the history 
and earlier work upon the subject the reader is referred to the works 
of Kegaradec, Kennedy, Depaul, and Montgomery. 

The foetal heartbeat, after the eighteenth or twentieth week of preg¬ 
nancy, should be detected without difficulty. Ordinarily it varies in fre¬ 
quency from 120 to 140 beats to the minute, and is a double sound, 
closely resembling the tick of a watch under a pillow. In order to hear it 
the abdomen should be bared, or at most covered by a thin cloth. In the 
earlier months it is best detected by means of a stethoscope, but at a 
later period the direct application of the ear gives more satisfactory 
results. One should not be content with merely hearing the foetal heart, 
but should always attempt to count its rate and compare it with that 
of the maternal pulse. 

In the early months the heart should be sought just over the sym¬ 
physis pubis; but in the later months the situation at which it is best 
heard varies according to the position and presentation of the foetus, 
details concerning which will be given when we consider the methods of 
obstetrical examination. 

The rate of the foetal heart is subject to considerable variations, 
which afford us a fairly reliable means of judging as to the well-being 
of the child. As a general rule, its life should be considered in danger 
when the heartbeats fall below 100 or^exceed-160. Following Franken- 
hauser’s publication in 1859, various writers have stated that there 
is a marked difference in the rapidity of the heartbeat in the two sexes, 
and that a rate of 124 or less indicates a hoy, and 144 or more a girl. 
Subsequent investigation, however, has failed to confirm their conclu¬ 
sions, as a positive diagnosis can be made by this means in only about 
50 per cent, of the cases. Indeed, there is no method by which the sex 
can be definitely determined before birth, except occasionally in breech 
presentations, when the genitalia can be differentiated by the examin¬ 
ing finger. 

In women possessing very thin abdominal and uterine walls the im- 



208 


DIAGNOSIS AND DURATION OF PREGNANCY 


pulse of the foetal heart may occasionally be appreciated by direct pallia¬ 
tion, especially when the child is lying in the right mento-iliac position. 
Such observations have been reported by Fischel, Duval, and others. 

Other Sounds Which May Be Heard on Auscultation. —In addition 
to hearing the foetal heart, auscultation of the abdomen in the later 
months of pregnancy often reveals other sounds, the most important of 
which are the funic souffle, the uterine or placental souffle, sounds due to 
movements of the foetus, the maternal pulse, and the gurgling of gas in 
the intestines of the mother. 

The funic souffle is a sharp, whistling sound, synchronous with the 
foetal pulse, which can be heard in about 15 per cent, of all cases. It is 
very inconstant in its appearance, as it may be recognized distinctly at 
one examination and be absent on succeeding occasions. It was first 
described by Evory Kennedy, who supposed that it was due to some 
interference with the circulation of the blood through the umbilical ar¬ 
teries, and subsequent investigations have served to confirm his conclu¬ 
sions. Its mode of production may occasionally be demonstrated in 
very thin women, in whom the umbilical cord may be palpated between 
the body of the child and the uterine wall, and on making pressure 
upon it with the stethosocope a distinct souffle can occasionally be elicited. 
This is not, however, a sign of very great importance, although, when 
heard, it is distinctly characteristic of pregnancy. 

The uterine souffle is a soft, blowing sound, synchronous with the 
maternal pulse, and is usually most distinctly heard upon auscultating 
the lower portion of the uterus. It is due to the passage of blood through 
the dilated uterine vessels. This sound was first described by Kegaradec, 
who considered ‘that it was produced by the circulation of the blood 
through the placenta. He therefore designated it as the placental souffle, 
and believed that it was of value in determining the situation of that 
organ. Subsequent investigations, however, have shown that such is 
not the case, and that the sound originates as I have indicated. As 
stated by Rotter and others, it may occasionally be appreciated by the 
palpating finger. This sign is not characteristic of pregnancy, as it 
may be present in any condition in which the blood supply to the 
genitalia becomes markedly increased, and accordingly may be heard in 
non-pregnant women presenting tumors of the uterus or ovaries. 

Certain movements of the feetus may likewise be recognized on auscul¬ 
tation. According to Ahlfeld, it is impossible to hear the movements of 
the extremities, but he considers that the sounds which are usually so 
interpreted are produced by spasmodic contractions of the diaphragm, 
and are analogous to singultus. 

The maternal pulse can frequently be distinctly heard on auscul¬ 
tating the abdomen, and in some instances the pulsation of the aorta is 
so violent as to communicate a distinct throb to the ear. Occasionallv, in 
neurotic women, the pulse may become so rapid during examination as to 
mask the fcetal heart sounds. 

In addition to the sounds just mentioned, it is not unusual to hear 
certain others produced by the passage of gases or fluids through the 
intestines of the mother. 


POSITIVE SIGNS OF PREGNANCY 


209 


Mapping Out the Outlines of the Foetus. —In the second half of preg¬ 
nancy it is possible to distinguish the outlines of the foetus by palpation 
through the abdominal walls, and this becomes easier the nearer term is 
approached. When it is desired to map out the foetus the examination 
should be made in a methodical manner, following the rules which will 
be given later. 

A diagnosis of pregnancy should not be made from this sign alone, 
unless one is able to feel distinctly the various portions of the foetus and 
to distinguish its head, breech, back, and extremities. Subserous myo¬ 
mata occasionally simulate the head or small parts, or both, and may 
occasionally give rise to serious diagnostic errors. 

Movements of the Foetus. —The third positive sign of pregnancy is 
present whenever the physician is able to feel the spontaneous movements 
of the foetus. 

After the fifth month the active movements may be felt at intervals 
on placing the hand over the abdomen. These vary from a faint flutter 
in the early months to quite violent motions at a later period, which are 
sometimes visible as well. Occasionally, somewhat similar sensations 
may be produced by contractions of the intestines or the muscles of the 
abdominal wall, though these should not deceive an experienced observer. 

The passive movements , obtained by ballottement, consist in the re¬ 
bound of a foetal extremity when displaced from its position by the 
examining finger, whereby a sensation is afforded similar to that pro¬ 
duced when a sudden motion is given to a piece of ice in a glass of 
water, so that at first it sinks and then slowly comes back to the 
finger. This sign is available from the early part of the fourth month, 
and may be obtained through either the vagina or the abdominal walls. 
To obtain vaginal ballottement the patient should be on her back; the 
physician then introduces two fingers into the vagina and carries them 
up to the anterior fornix, to which he imparts a sudden motion with 
his finger-tips, afterwards retaining them in the same position. After a 
moment the extremity of the child, which occupies the lower segment of 
the uterus, usually the head, drops down upon them again. 

External ballottement can be obtained by imparting a sudden motion 
to the portion of the abdominal wall covering the uterus; in a few seconds 
the rebound of one of the extremities or of the head of the foetus can be 
felt. This sign, while not absolutely positive, is of very considerable 
value, as it can be simulated only by a pedunculated tumor swimming 
in ascitic fluid. 

The X-ray. —Whenever the outlines of the foetal skeleton can be 
distinguished by means of the Koentgen rav, the existence of pregnancy 
is assured. Unfortunately, like the other positive signs, this method 
of diagnosis is not available until the second half of pregnancy. By 
its means Bartholomew, Sale and Calloway were able to make a positive 
diagnosis in one-third of their patients at the fifth month, in one half 
at the sixth month, and almost constantly later. In my experience, the 
method has been of especial value in differentiating the pregnant uterus 
from abdominal tumors of other origin, particularly when the child is 

dead. 


210 


DIAGNOSIS AND DURATION OF PREGNANCY 


Peterson claims that the employment of the X-ray in association 
with artificial pneumoperitoneum permits a positive diagnosis as early 
as the sixth or eighth week. In this event, the decision is not based upon 
the recognition of foetal bones, but rather upon the detection of changes 
in the lower uterine segment. These changes consist in an enlargement 
of the isthmus of the uterus in its long axis, together with a lateral 
widening. I have had no experience with the method, but, in view of 
Peterson’s well known conservatism, I am prepared to accept his state¬ 
ments. 

Probable Signs of Pregnancy.—These consist in (1) enlargement of 
the abdomen; (2) changes in the shape, size and consistency of the 
uterus; (3) changes in the cervix; (4) the detection of intermittent con¬ 
tractions of the uterus; and (5) the positive outcome of Abderhalden’s 
serum reaction. 

Enlargement of the Abdomen. —From the third month onward the 
uterus can be felt through the abdominal walls" a~s a tumor, which gradu¬ 
ally increases in size up to the end of pregnancy. Generally speaking, 
any enlargement of the abdomen during the childbearing period should 
be regarded as prima facie evidence of the existence of pregnancy. Figs. 
183, 184, 185, and 186 give a good idea of the changes in the shape of 
the abdomen at the various months. 

The abdominal enlargement is less pronounced in primiparae than 
in multiparae, for the reason that in the latter the abdominal walls have 
lost a great part of their tonicity and are sometimes so flaccid that they 
afford little or no support to the uterus, which then sags forward and 
downward, giving rise to a pendulous abdomen. This difference is so 
apparent that it is not unusual for women in the latter part of a second 
pregnancy to suspect the existence of twins from the increased size of the 
uterus, as compared with that noted in the corresponding month of the 
previous pregnancy. It should also be borne in mind that the abdomen 
changes its shape materially according as the woman is in the upright 
or horizontal position, being much less prominent when she is lying 
down. (See Fig. 181, b.) 

—Changes in Size, Shape, and Consistency of Uterus. —In the first 
three months these are the only physical signs available, and the existence 
of an enlarged uterus at any time during the childbearing period should 
be regarded, as presumptive evidence of pregnancy, until such a possibility 
has been conclusively eliminated. 

During the first few weeks the increase in size is limited almost en¬ 
tirely to the anteroposterior diameter; but at a little later period the 
body of the uterus becomes almost globular in shape, and at the third 
month attains the size of an orange. During the first two months the 
pregnant uterus still continues to be entirely a pelvic organ, whereas 
during the third month it begins to rise above the symphysis. At the 
same time the angle between the body and cervix becomes accentuated 
—in other words, the physiological anteflexion is increased. 

More characteristic than the changes in shape are those affecting 
its consistency. On bimanual examination the uterine body offers a 
doughy or elastic sensation, and in many instances becomes so soft as 


PROBABLE SIGNS OF PREGNANCY 211 

to be hardly distinguishable. Dickinson has pointed out that these 
changes can be noted at a very early period. 

According to R. von Braun, it would appear that as early as the first 
week evidence of pregnancy is afforded by the appearance of a more or 
less longitudinal furrow upon either the anterior or posterior surface 
I of the uterus. Its presence he attributes to changes in consistence and 
the alternation between contraction and relaxation of the portion of the 
i organ in which the ovum is situated. 






At about the sixth week another sign of very considerable value—the 
so-called lie gar s sign —becomes available. On careful examination with 
one hand upon the abdomen and two fingers of the other hand in the 
vagina, the firm, hard cervix is felt, and above it the elastic body of the 
uterus, while between the two the isthmus is felt as a soft compressible 
area. Occasionally the change in consistence in this location is so 
marked that no connection between the cervix and body appears to exist, 
so that inexperienced observers may mistake the cervix for a small uterus, 
and the softened body for a tumor of the tubes or ovaries. 



Figs. 183-186. —Showii g Relative Abdominal Enlargement at Third, Sixth, Ninth, 

and Tenth Month of Pregnancy. 


Fig. 183. 


Fig. 184. 


Fig. 185. 


Fig. 186. 












212 


DIAGNOSIS AND DURATION OF PREGNANCY 



The value of this sign, which was first described in 1884, by Reinl, 
one of Hegars assistants, is universally admitted, and 1 consider it 
the most valuable sign of early pregnancy. Its production probably 
depends upon the forcing of the ( a11 the ovum occupying the loAver 
uterine segment into the uppi i pur body of the uterus, so that the 

empty and softened lower u so nt can then be readily com¬ 

pressed between the fingers. I (88 gives a good idea of the sensation 
to be obtained on bimanual ( m. ut'or ; and Figs. 189 and 190 show 
the condition of the uterus ay h ma. s t possible. This sign is not, 

h o w e v e r, absolutely 
characteristic, as it 
may occasionally be 
elicited when the walls 
of the non-pregnant 
uterus are unduly soft. 

Macdonald in 1908 
directed attention to 
a modification of 
HegaFs sign, lvhich he 
claims will make pos¬ 
sible the diagnosis of 
pregnancy during the 
course of the first 
month. It is based 
upon the exaggerated 
flexibility of the isth- 
nms of the uterus, and 
;> manifested by the 
unusual case w i t h 
Avh ch the fundus and 
cer\ ix can be brought 
t( ther on vaginal 
m.i! pulation. 

nancy, the cervix 
omen the os ex- 
h. i < btained by press- 


\ D.ifr' 


Fig. 187. 


Pendulous Abdomen in a Multi \hox 
AVoman with Normal Pelvis. 


Cervix .—Beginning with the second month < 
becomes considerably softened, and in prbnipn 
ternum offers to the finger a sensation similar to 
ing upon the more yielding lips instead o the h a>T cartilage of the 
nose, as at other times. Occasionally, however, I' . softening does not 
occur until much later in pregnancy, and in certain lmlammatory con¬ 
ditions, as Avell as in carcinoma, the cervix ay * 1 ' 1 firm and hard 
until the onset of labor. 

Intermittent Contractions of the Uteri le first iveeks 

on, at intervals of from three to ten minutes, - p <. i r uterus under¬ 


goes painless contractions, which in the early 
by bimanual examination, and later by the 
when the previously relaxed organ is felt tc 
remaining so for a few moments, and then retu 
dition. Attention was first called to this phenol 
and the sign has since been knoAvn by his name 


i t 


oe appreciated 
the abdomen, 
l m and hard, 
original con- 
axton Hicks, 
however, in- 


:iOl 






PROBABLE SIGNS OF PREGNANCY 


213 


fallible, as it is probable that similar contractions occur in the non¬ 
pregnant organ, as has been demonstrated by Keve in the pig and other 
animals. Moreover, similai contractions are sometimes observed in hem- 
atomctra, and occasionally in cases of soft myomata. 

Whenevei one or several of these probable signs of pregnancy are 
detected the evidence becomes very strong. Nevertheless, if there is any 
possibility of wronging our patient we are not justified in making a posi¬ 
tive assertion, even though we may feel morally sure of our diagnosis, 
until the positive signs become available 



Fig. 188 .—Method of Detecting Hegar’s Sign. 


Abderhalden’s Reaction .—Abderhalden in 1912 described what he 
believed to be an absolute method for diagnosticating the existence of 
pregnancy by means of certain changes occurring in the blood serum of 
the patient. He reasoned that if foetal elements are constantly escap¬ 
ing into the maternal blood current, as is undoubtedly the case, some 
mechanism must be developed in order to render the foreign protein 
harmless. He assumed that this is accomplished by the development of 
a ferment in the maternal hlood which breaks down the foetal tissue into 
simpler substances; and, consequently, that the blood serum oi preg¬ 
nant women should possess the power of breaking down placental tissue 
into its component amino acids. 

He then devised a method for demonstrating this reaction in vitro, 
extremely simple in conception, but very difficult in exact application. 




















214 


DIAGNOSIS AND DURATION OF PREGNANCY 


It consists in placing in a small dialysing tube a definite quantity of 
especially prepared placental peptone and 1 or 1.5 cm. of the serum to be 
tested. The dialysing tube is then introduced into a small flask con¬ 
taining distilled water and placed in the thermostat for 16 hours. By 
the end of this time the specific ferment, if present, will have broken 
down at least a part of the placental peptone, when the resulting amino 
acids, together with a portion of the salts, will diffuse out into the 
distilled water, while the colloidal material remains within the tube. 

The presence of amino acids in the dialysate is then determined by 
means of the biuret test, or by means of a 1 per cent, solution of 
triketohydrindenhydrate (ninhydrin), the latter giving a delicate purple 
color upon heating. Or, as was suggested by Abderhalden and Fodor 
in 1914, they can be detected by the estimation of the total nitrogen 
by the microkjeldahl method. Abderhalden also pointed out that more 



Fig. 189. —Ten Weeks’ Pregnant Uterus Fig. 190. —Showing Mode of Produc- 
(Pinard). X p2- tion of Hegar’s Sign. 


accurate results could be obtained by means of the polarimeter, which 
has the further advantage of obviating the use of dialysing tubes. 

This work aroused the greatest interest, was repeated in all parts 
of the world, and promptly gave rise to an immense literature, whose 
mere enumeration required 36 pages in the 4th edition of Abderhalden’s 
“Abwehrfermente,” which appeared two years after his initial publi¬ 
cation. 

Abderhalden states that the reaction becomes available in the earliest 
weeks and persists throughout the entire duration of pregnancy, to 
disappear in the first days of the puerperium. He considers that a posi¬ 
tive result affords indubitable evidence of the existence of pregnancy, 
and that unsatisfactory results are always attributable to imperfect 
technic. On the other hand, Williams and Pearce, Petri and others con¬ 
tend that the reaction is not specific, and may occur in non-pregnant 
women or even in men. Bar and Ecalle in 1919 found that the reaction 
was positive in all the pregnant women tested, but likewise obtained a 
similar result in 34 per cent, of patients in whom pregnancy did not exist. 







PRESUMPTIVE SIGNS OF PREGNANCY 


215 


Consequently they concluded that a positive result has no diagnostic 
significance, while a negative one excludes the possibility of pregnancy. 

Van Slyke in 1915 devised a quantitative method for determining 
the amount of amino acids which are liberated by the action of blood 
serum upon placental peptone. He experimented with serum obtained 
from men, non-pregnant and pregnant women; and as he found essen¬ 
tially the same quantities in each, he was forced to deny the presence of 
a specific ferment in the blood of pregnant women, and to conclude that 
the reaction is not characteristic of pregnancy. 

Whether these conclusions are correct or not, the method has been 
but little used since the World War, and a communication by Abder- 
halden in 1921 indicates that he has become somewhat skeptical as to 
its value, or, at least, as to its interpretation. It should, however, be 
regarded as an important contribution to medical investigation, as it 
has-served to focus attention upon the important fact that foetal ele¬ 
ments are continually gaining access to the maternal circulation—a 
phenomenon which cannot be regarded as negligible. 

Presumptive Signs of Pregnancy.—The presumptive evidences of 
pregnancy are afforded in great part by subjective symptoms, which may 
be appreciated by the patient herself. These consist in (1) cessation of 
the menses, (2) changes in the breasts, (3) morning sickness, (4) 
quickening, (5) discoloration of the mucous membranes, (6) abnor¬ 
malities in pigmentation, (7) disturbances in urination, (8) mental and 
emotional changes, (9) diminished tolerance for sugar, and (10) changes 
in the blood serum. 

Cessation of the Menses .—Most important is the cessation of the 
menstrual flow. In women exposed to the possibility of pregnancy, and 
whose menses have previously been regular, a sudden cessation is a most 
characteristic sign; and from it alone the majority of married women 
do not hesitate to diagnosticate their condition. But in patients present¬ 
ing an irregular menstrual history this symptom does not possess the 
same diagnostic value, as we know that certain diseases may give rise to 
amenorrhea of many months' duration, in the course of which conception 
occasionally occurs. 

Furthermore, a single menstrual period may be missed by women 
who fear the possibility of pregnancy. On the other hand, false state¬ 
ments are often made, and a patient who has missed one or more periods 
may complain of profuse uterine hemorrhage, in the hope of misleading 
the physician and inducing him to curette the uterus. 

In not a few instances menstruation may appear once after the com¬ 
mencement of pregnancy, though the flow is usually less profuse than at 
other times. In many of these cases it is probable that conception has 
occurred shortly before the period. Only very rarely, however, does the 
menstrual flow appear more than once, and, although its regular recur¬ 
rence is theoretically possible until the decidua vera and capsularis fuse 
together at the fourth month, yet repeated bleeding should always arouse 
suspicion as to the existence of disease of the endometrium, carcinoma 
of the cervix, or some other pathological condition. 

One occasionally hears of women who menstruate regularly through- 


2 JO 


DIAGNOSIS AND DURATION OF PREGNANCY 


out pregnancy, but the majority of these accounts are apocryphal, or else 
the condition is associated with uterine disease. 

Changes in the Breasts. —In the chapter upon the Physiology of 
Pregnancy reference has already been made to the changes which occur 
in the breasts. Generally speaking, in primiparae these are quite char¬ 
acteristic, but are of less value in multiparae, since the breasts of the 
latter not infrequently contain a small amount of milk or colostrum for 
months, or even for years, following the last labor. Occasionally, changes 
in the breasts similar to those produced by pregnancy may be observed 
in women suffering with ovarian or uterine tumors. Nor is the pos¬ 
sibility of their occurrence excluded in instances of sp_ui’ious-or imaginary 
pregnancy. 

Nausea and Vomiting. —The establishment of pregnancy is frequently 
manifested by disturbances of the digestive system, more particularly 
manifested by nausea and vomiting. This “ morning sickness /’ as the 
name implies, usually comes on in the earlier part of the day, and passes 
off in a few hours, although it occasionally persists longer or may occur 
at other times. It usually appears about the end of the first month, and 
disappears spontaneously six or eight weeks later, although some patients 
suffer from it for a longer period. 

Occasionally, similar symptoms result from nervousness or from the 
fear of an illegitimate pregnancy, as well as in certain cases of pseudo 
cyesis. It is generally believed that these symptoms are observed in 
most pregnant women, but, upon analyzing the records of my private 
patients, I found that slightly less than one half of them suffered from 
vomiting. In many it amounts to nothing more than an occasional sen¬ 
sation of nausea; others have considerable vomiting, while in rare in¬ 
stances the nausea and vomiting may be so persistent and constant as to 
interfere seriously with nutrition. It is then designated as pernicious 
vomiting, which will be considered in detail in Chapter XXVI. 

Quickening. —About the eighteenth or twentieth week the woman be¬ 
comes conscious of slight, fluttering movements in her abdomen, which 
gradually increase in intensity. These are usually due to movements of 
the foetus, and their first appearance is designated as “quickening” or 
the perception of life. Occasionally foetal movements may be perceived 
as early as the tenth week, while in rare instances they may not be ex¬ 
perienced at all. 

This sign offers only corroborative evidence of pregnancy, and is of 
no value unless confirmed by the hand of the physician, as in many 
nervous women similar sensations are experienced in its absence. 

Discoloration of the Mucous Membrane of Vagina and Vulva. —Un¬ 
der the influence of pregnancy the mucosa about the vaginal opening 
and the lower portion of the anterior vaginal wall frequently take on a 
dark bluish or purplish, congested appearance. Attention was first 
called to this condition by Jacquemier and Xluge, but particular stress 
was laid upon its significance by Dr. -Tames R. Chadwick, of Boston, so 
that in this country it is known as Chadwick’s sign. Its presence sup¬ 
plies valuable presumptive evidence, but is not conclusive, as it may 


PRESUMPTIVE SIGNS OF PREGNANCY 


217 


likewise be observed in any condition leading to intense congestion of 
the pelvic organs. 

1 ig mentation of the Shin and Abdominal Striae .—These manifesta¬ 
tions, which have already been referred to in the chapter upon the 
physiology of pregnancy, are usually observed in this condition, but are 
not absolutely characteristic of it, as they sometimes do not develop, 
and, on the other hand, may be associated with tumors of other origin. 

I rinary Disturbances .—In the early weeks of pregnancy the enlarg¬ 
ing uterus, by exerting pressure on the bladder, causes a desire for fre¬ 
quent micturition. This continues for the first few months, and 
gradually passes off as the uterus rises up into the abdomen, to reappear 
when the head descends into the pelvis a few weeks before term. 

Cravings—Mental and Emotional Changes .—Occasionally the appe¬ 
tite of the pregnant woman becomes very capricious, and she may evince 
an almost unconquerable desire for peculiar and sometimes revolting 
articles of food. I recall one patient who subsisted almost exclusively 
upon deviled crabs throughout the entire duration of pregnancy, and 
another who could retain nothing for the first few months except broiled 
lobster and Bass’s ale. 

Reference has already been made to the mental and emotional changes 
which sometimes characterize pregnancy, and occasionally we meet with 
women who diagnose their condition mainly from the occurrence of 
changes in their own temperament with which they have become familiar 
in previous pregnancies. 

Decreased Sugar Tolerance .—As the result of the demonstration by 
Niirnberger and others that the renal threshold for sugar is definitely 
lowered during the first months of pregnancy, Welz and Van Nest have 
utilized the phenomenon as a diagnostic test for the existence of early 
pregnancy. For this purpose, the fasting patient is catheterized and a 
specimen of blood taken; 150 grams of glucose are then give by mouth, 
and 45 minutes later the urine is tested for sugar, and afterwards at 
half hourly intervals. As soon as a positive result is obtained, a second 
sample of blood is withdrawn and its sugar content is determined. 
The authors consider that decreased^-tolerance and the existence of 
pregnancy is demonstrated, whenever glycosuria is present, and the sugar 
content of the blood does not exceed 190 milligrams to 100 c.c.m. They 
state that the accuracy of the test was confirmed by the subsequent 
history in all but 2 out of 44 patients, but that it is less accurate after 
the third month. I have had but little experience with the method, but 
as I know of several instances in which it would have led to an erroneous 
conclusion, I fear that its advocates have taken too roseate a view of its 
applicability. 

Changes in the Blood Serum.—In the preceding chapter reference 
was made to changes in the antitryptic titer, and in the cholesterin 
' content of the maternal serum which are said to characterize pregnancy. 
Fieux and Mauriac believe that in the early months it also contains an 
antibody whose presence can be revealed by the deviation of complement 
reaction, when young chorionic villi are used as antigen. The demon¬ 
stration of such changes, however, is too complicated for ordinary clinical 



218 


DIAGNOSIS AND DURATION OF PREGNANCY 


purposes. On the other hand, if the claims of Neumann and Hermann 
are substantiated, we may have at our disposal a valuable aid to diagnosis, 
which is attributable to an increase in the amount of lipoids present 
in the serum in the latter months of pregnancy. This reaction consists 
in adding a drop of distilled water to a filtered alcoholic extract prepared 
from one cubic centimeter of blood. The fluid becomes turbid if preg¬ 
nancy exist, while it remains clear and transparent in non-pregnant 
women. 

Linzenmeier claims that in early pregnancy diagnostic use can he 
made of the rapidity with which the corpuscles settle, as he found 
that they did so in two hours or less in pregnant women, instead of 
in six hours, as in the case with normal blood. 

Synopsis of Signs and Symptoms of Pregnancy. —For convenience of 
reference, we give a synopsis of the signs and symptoms of pregnancy, 
dividing them into three groups, according as they occur in the first 
three months, in the fourth and fifth months, or in the last five months 
of pregnancy. 

In the first period the symptoms are: (a) cessation of the menses, 
(b) changes in the breasts; (c) morning sickness; ( d) urinary disturb¬ 
ances. The signs are: (1) enlargement and softening of the body of the 
uterus and increased anteflexion; (2) changes in the consistency of the 
body of the uterus; (3) Hegar’s sign; (4) Abderhalden’s reaction; (5) 
changes in the cervix; (6) Chadwick’s sign; (?) the abdomen is not 
prominent, the navel is depressed; (8) auscultation is negative. 

Second period. Symptoms: (a) menses still absent; (&) more 
marked changes in the breasts; (c) disappearance or subsidence of gastric 
and urinary disturbances; (cl) quickening. Signs: (1) the fundus is 
felt several fingers above the symphysis at the forth month, and mid¬ 
way between the symphysis and umbilicus at the fifth month; (2) the 
cervix is soft; (3) ballottement is obtainable; (4) intermittent uterine 
contractions are recognizable; (5) at the very end of the period the foetal 
heart sounds can be distinguished; (6) Abderhalden’s reaction. 

Third period: Symptoms: (a) menses still absent; (b) changes in 
the breasts more marked; (c) in the last month frequent urination re¬ 
appears, often with neuralgic pains in the lower extremities. Signs: 
(1) progressive enlargement of the abdomen; (2) umbilicus smooth and 
later protruding; (3) the foetal heart can be heard; (4) the different 
parts of the child can be palpated; (5) foetal movements are perceptible; 
(6) positive X-ray findings; (7) Abderhalden’s reaction. 

In the first period the diagnosis is usually very probable, but never 
absolute; in the second, very rarely doubtful, and in the third absolute. 

Differential Diagnosis of Pregnancy. —The pregnant uterus is often 
mistaken for other tumors occupying the pelvic or abdominal cavities, 
and vice versa , though, as a rule, the former mistake is more frequently 
made. The early periods of pregnancy may be simulated by enlargement 
of the uterus due to interstitial or submucous myomata, sarcoma, 
hematometra, and conditions resulting from inflammatory disturbances. 
As a rule, the uterus in these circumstances is harder and firmer than 
in pregnancy, and does not present its characteristic elastic or boggy con- 


221 


DIAGNOSIS OF THE LIFE OR DEATH OF THE FOETUS 

tip the finger until the very end of pregnancy; and during the last 
four to six weeks of pregnancy the presenting part is found engaged 
in the superior strait, unless some disproportion exists. 

In multiparous women, on the other hand, the abdominal walls are 
usually lax, flabby, and frequently pendulous, and the uterus is readily 
palpated through them. In addition to the pinkish striae due to the 
present condition, the silvery cicatrices of past pregnancies may also be 
noted. I he bi easts are usually not as firm as in the first pregnancy, 
and frequently present striae similar to those observed on the abdomen. 
I he vulva is usually more or less gaping, the frenulum has disappeared, 
and the hymen is replaced by the carv jwu lae m yrtiformes. The external 
os, even in the early months of pregnancy, usually shows signs of lacera¬ 
tion, and at a little later period readily admits the tip of the finger, 
which-can be carried up to the internal os. Furthermore, in the ma¬ 
jority of cases the presenting part does not engage in the superior strait 
until the onset of labor. 


Diagnosis of the Life or Death of the Foetus.—Generally speaking, the 
foetus should be considered to be alive unless definite evidence to the con¬ 
trary can be adduced. In the early months of pregnancy the diagnosis 
of foetal death offers considerable difficultv, and can be made only after 
repeated examinations have demonstrated that the uterus has remained 
stationary in size for a number of weeks. 

In the later months of pregnancy, the disappearance of foetal move¬ 
ments usually directs the attention of the patient to this possibility; 
moreover, she may suffer from ill-defined sensations, such as chilliness, 
l angu or, a s ensation of weight in the abdomen, and perhaps a foul taste 
in the mouth. Careful investigation shows that the uterus does not cor¬ 
respond in size with the estimated duration of pregnancy, or even has 
become smaller than previously; while at the same time retrogressive 
changes have occurred in the breasts, which have become soft and flabby. 
The diagnosis cannot usually lie made at a single examination, and is 
permissible only after repeated examinations, when in addition to the 
signs just mentioned one has failed to hear the foetal heart or perceive 
the movements of the child. 

Occasionally, a positive diagnosis can be made at once by palpating 
the macerated skull through the partially dilated cervix ; in this event 
one feels that the bones of the head are loose and present a sensation as 
if they were contained in a flabby bag. Spalding claims that a positive 
diagnosis of foetal death can be made bv the employment of the 
Roentgen ray. In such cases the plate will show overlapping of the 
bones of the skull at the several sutures, associated with distinct signs 
of shrinkage of the skull contents. I have as yet had no experience 
with the method, but I am prepared to believe that it may sometimes 
serve a useful purpose. 

Duration of Pregnancy.—As we have no means of ascertaining the 
exact date at which fertilization occurs, it is apparent that strictly 
accurate statements as to the duration of pregnancy cannot be made. 
Although conception may occur at any time, the researches of Fraenkel 
indicate that it is most usual somewhere about the middle of the inter- 






222 


DIAGNOSIS AND DURATION OF PREGNANCY 


menstrual period. Usually labor ensues about two hun dred and eighty 
days (ten lunar months) after the first day of the last menstrual period, 
so thatPOie actual duration of pregnancy is two hundred and seventy 
days, or less. This rule, however, is subject to many exceptions, as 
apparently well-developed children may be born as early as the two 
hundred and fortieth and as late as the three hundred and twentieth 
day after the last menstrual period. 

Every one practicing obstetrics occasionally meets with cases in which 
the patient believes that she has passed a month beyond term; or, in 
other words, that the pregnancy has lasted eleven lunar months. This 
belief, however, is usually erroneous, and in the majority of cases is due 
to some miscalculation. Exceptionally, however, pregnancy may last 
for an abnormally long period, and I recall a patient who on two 
occasions did not fall into labor until considerably over eleven months 
after the last period. In both instances the children weighed over 12 
pounds, were 55 centimeters in length, and presented markedly increased 
thoracic measurements. 

Winckel, after carefully studying his material, states that about 
one-seventh of all children weighing 4,000 grams or more (9 pounds) 
have been carried for three hundred and two days or longer after con¬ 
ception, and that in very exceptional instances pregnancy may last as 
long as three hundred and thirty-six days. According to the German 
law, three hundred and two days after the last period constitutes the 
limit for legitimacy. Recently, this has given rise to considerable dis¬ 
cussion, and it appears that strict application of the law sometimes results 
in great injustice. Siegel states that this term is frequently exceeded 
and may be as long as three hundred and thirty-one days. 

Even when we know the date of the coitus from which the pregnancy 
has resulted, we are in no better position to estimate the actual length of 
pregnancy, inasmuch as Lowenhardt has pointed out that two women 
may have fruitful coitus on the same day, and yet the date of their de¬ 
liveries may vary markedly. Ahlfeld analyzed four hundred and twenty- 
five cases in which the date of coitus was supposed to be known, and 
found the average duration of pregnancy to be 269.91 days; but indi¬ 
vidual cases in the series varied from between two hundred and thirty- 
one to three hundred and twenty-nine days. 

Similar differences are reported by veterinarians, who usually date 
the beginning of pregnancy from a single coitus. For example, the 
average duration of pregnancy in the mare is three hundred and sixty- 
six days, but in a large series of cases individual variations between 
three hundred and seven and four hundred and twelve days were noted. 
In the cow the normal duration is placed at two hundred and eighty 
days, with extremes of two hundred and forty and three hundred and 
eleven days. Again, as Mme. Laurie has shown, the duration of preg¬ 
nancy also depends upon the extent to which the patient can spare herself 
during the last three months of pregnancy. This observer found that it 
was twenty days longer in 1,550 women who lived comfortably in a 
hospital for several months prior to delivery than in the same number of 
women who entered at the onset of labor. Her figures, then, go to show 



ESTIMATION OF THE PROBABLE DATE OF CONFINEMENT 223 


that hard work in poorly nourished women predisposes to the premature 
ending of pregnancy. 

In view of these facts we must conclude that the duration of preg¬ 
nancy varies within certain limits, which probably depend upon individ¬ 
ual peculiarities, and that it sometimes exceeds two hundred and eighty 
days from the last menstrual period. Generally speaking, however, pro¬ 
longation of pregnancy should not be assumed unless the child weighs 
at least 4,000 grams and the history indicates that eleven lunar months 
have elapsed since the last menstruation. As the post-mature child may 
give rise to serious dystocia by its mere size, it is the part of wisdom to 
regard with suspicion every patient whose menstrual history indicates 
that she has passed beyond the tenth lunar month, and to make weekly 
examinations in which particular attention is directed toward the size 
of the’child and evidence of disproportion between its head and the pelvic 
inlet, and labor should be induced as soon as one is convinced that the 
normal proportions are exceeded. 

Estimation of the Probable Date of Confinement.—Unfortunately for 
the comfort of the patient, as well as of the physician, we possess no 
reliable means of es¬ 
timating the exact 
date, but are obliged 
to content ourselves 
with the method pro¬ 
posed by Naegele, 
which is based upon 
the belief that labor 
occurs two hundred 
and eighty days from 
the beginning of the 
last menstrual pe¬ 
riod, The calcula¬ 
tion is readily made 
by adding §ev£H_days 
to the date at which 
the last menstrual 
period first appeared, 
and then counting 
back three months. 

For example, if the 
last period began on 
January 10th, we 
add seven days, mak- 

ing January 17, and jr IG 192 .—Relative Height of the Fundus at the 
count back three Various Weeks of Pregnancy. 

months, thus fixing 

upon October 17th as the probable date of confinement. 

In a small number of cases the patient will be confined on the precise 
day estimated, and in the great majority oi cases within a few daws of 
it; but occasionally a period of several weeks may elapse before labor 
























224 


DIAGNOSIS AND DURATION OF PREGNANCY 


occurs. Accordingly, the physician should hesitate to predict a definite 
day for the confinement, and should always allow a margin of two to 
three weeks in his calculations, I have made the interesting observation 
that in many young women who miss the first menstrual period after 
marriage, a fully developed child is born two hundred and eighty days 
from the beginning of the last menstrual period. As this is less than 
nine calendar months after the date of marriage, it would indicate that 
pregnancy does not always last as long as ten lunar months. 

Lowenhardt believed that the duration of pregnancy was ten men¬ 
strual periods, and considered the labor as likely to occur when the tenth 
period following conception fell due, and Sc-hatz has adduced consid¬ 
erable evidence along similar lines. Accordingly, in patients menstruat¬ 
ing at intervals of twenty-six or thirty days, for example, the duration of 
pregnancy would he two hundred and sixty or three hundred days 
respectively. In the long run, however, this method of calculation does 
not give more accurate results than that of Naegele. 

Occasionally the patient believes that she can date her pregnancy 
from a single coitus, and prefers to estimate the approaching date of 
confinement from that rather than from the beginning of the last period. 
This method is subject to quite as great an error as if calculated from 
the latter date, as we have no means of ascertaining when ovulation 
takes place, nor how long the spermatozoa may remain in the genital 
tract before conception occurs. 

Frequent attempts have been made to estimate the date of confine¬ 
ment by adding twenty or twenty-one weeks to the date upon which the 
patient first perceived foetal movements. This method is founded on the 
belief that quickening is first experienced at the eighteenth or twentieth 
week of pregnancy. Unfortunately, this assumption is erroneous, as the 
symptom is frequently first noticed at a much earlier period, and some¬ 
times not until considerably later. 

In not a few instances, especially in nursing women, conception may 
take place during a period of amenorrhea, and the patient is often sur¬ 
prised by the enlargement of her abdomen or by the perception of foetal 
movements; while occasionally the first intimation that she is pregnant is 
given by the fact that her milk, which has previously agreed very well with 
the infant, suddenly becomes indigestible. Under such circumstances, 
the usual methods of calculation are of no value, and we have to depend 
upon other means, which, unfortunately, are extremely unsatisfactory. 

In such cases our calculations are based upon the enlargement of the 
abdomen and the height to which the fundus of the uterus has risen. 
Generally speaking, with the patient on her back, we find that the fundus 
at the fourth month is several fingexs. -breadths above the symphysis 
pubis; at the fifth month midway between it and the umbilicus; at the 
sixth month at the level of the umbilicus; at the seventh month three 
fingers’-breadths above the umbilicus; at the eight month an equal dis¬ 
tance above its position at the seventh month; at the ninth month just 
below the xiphoid; whereas in the last month, particularly in primi- 
parous women, it sinks downward and assumes almost the position it 
occupied at the eighth month. 


LITERATURE 


225 


Phis method, however, gives only approximate results, as the position 
oi the umbilicus is subject to marked variations, while the distention of 
the uterus is dependent not only upon the size of the child, but also upon 
the quantity of amniotic fluid. According to Spiegelberg, the situation 
cf the umbilicus varies from 13 to 28 centimeters above the symphysis, 
so that there may be a difference of 6 inches in its position. On this 
account it has been thought preferable by some authors to estimate the 
distance of the fundus from the symphysis pubis with a tape measure, 
the average results obtained by Spiegelberg being as follows: 


22 d to 28tli week . 24 to 24.5 

28th week . 26.7 

30tli “ . 28.4 

32d “ . 29.5 to 30 

34th “ . 31 

36th “ . 32 

38th “ . 33.1 

40th “ . 33.7 


centimeters. 

i l 
( ( 

( l 
C i 
i i 
( ( 

( t 


These measurements, likewise, are subject to considerable variations, 
as they are dependent not only upon the size of the foetus contained 
within the uterus, but also upon the degree of distention of the abdominal 
contents. Nevertheless, in cases in which we possess no other data, they 
occasionally afford us information of very considerable value. 


LITERATURE 

Abderhalden. Die Serodiagnostik der Schwangerschaft. Deutsche med. Wocken- 
schr., 1912, Nr. 46. 

Abwehrfermente. IV. Aufl., Berlin, 1914. 

Weitere Studien iiber das Wesen der sogenannten Abderhaldenschen Reaktion. 
Fermentforschung 1921, iv, 338-358. 

Ahlfeld. Beobachtungen iiber die Dauer der Schwangerschaft. Monatsschr. f. 
Geburtsk., 1869, xxxiv, 180-225. 

Die wahrnehmbaren kindlichen Bewegungen. Lehrbuch der Geburtshiilfe, II. 
Aufl., 1898, 56. 

Bar and Ecalle. De la utilization pour le diagnostic de la grossesse des recentes 
deeouvertes biologiques. Archives Mens, d’obst. et de gym, 1919, viii, 372-400. 
Bartholomew, Sale and Calloway. Diagnosis of Pregnancy by the Roentgen 
Ray. Jour. Am. Med. Assoc., lxxvi, 912-918. 

Bexoist. Des rapports entre 1 ’embryon et le placenta dans 1 ’avortement. These 
de Paris, 1906. 

Bichebois. Contribution a 1 ’etude de l’idee de grossesse, trouble psyehopathique. 
These de Nancy, 1903. 

vox Braun. Ueber Friihdiagnose der Graviditat. Zentralbl. f. Gym, 1899, xxiii, 
488-489. 

Budin. Femmes en couches et nouveau-nes. Paris, 1897, 1-4. 

Chadwick. Value of the Bluish Coloration of the Vaginal Entrance as a Sign of 
Pregnancy. Trans. Amer. Gym Soc., 1886, xi r 399. 

Depaul. Traite d’auscultation obstetricale. Paris, 1847. 

Dickinson. The Diagnosis of Pregnancy between the Second and Seventh Weeks 
by Bimanual Examination. Amer. Gym and Obst. Jour., 1892, ii, 544- 
555. 












226 


DIAGNOSIS AND DURATION OF PREGNANCY 


Duval. Palpation of the Foetal Heart Impulse in Pregnancy. Johns llopkins 
Hospital Bulletin, 1897, viii, p. 207. 

Fieux ct Mauriac. De la possibility d ’une toxemie villeuse et d ’mi sero diagnostic 
de la grossesse. Annales de gyn. et d’obst., 1910, N. S. vii, 65-75. 

Fischel. Ueber ein bisher nicht beobachtetes Phanomen bei Deflexionslagen. 
Prager med. Wochenschr., 1881, Nr. 12, 13; 1882, Nr. 28. 

Zur intrauterinen Tastbarkeit des fotalen Herzimpulses bei Deflexionslagen. 
Zentralbl. f. Gyn., ix, 1885, 769-771. 

Frankenhauser. Ueber die Herztone der Fruclit und ihre Benutzung zur Diag¬ 
nose des Geschlechts derselben, etc. Monatsschr. f. Geburtskunde, 1859, xiv, 
161-174. 

Hicks. On the Contraction of the Uterus throughout Pregnancy. Trans. London 
Obst. Soc., 1872, xiii, 216-231. 

Kegaradec. Memoire sur 1 ’auscultation appliquee a 1 ’etude de la grossesse. Paris, 
1822. 

Kennedy. Observations on Obstetric Auscultation. New York, 1847. 

Keye. Periodic Variations in Spontaneous Contractions of Uterine Muscle, etc. 

Bull. Johns Hopkins Hospital, 1923, xxxiv, 60-63. 

Laurie. De 1’influence du repos sur la duree de la grossesse. These de Paris, 
1899. 

Linzenmeier. Eine neue Schwangerschaftsreaktion. Zentralbl. fur Gyn., 1920, 
816-820. 

Lowenhardt. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. 
Gyn., 1872, iii, 456-491. 

Macdonald. The Diagnosis of Early Pregnancy. Am. J. Obst., 1908, lvii, 323-346. 
Mayor. Quoted in Bibliotheque universelle de Geneve, November, 1818, ix. 
Montgomery. An Exposition of the Signs and Symptoms of Pregnancy, 2d ed., 
London, 1863. 

Neumann u. Hermann. Biol. Studien iiber die weibliche Keimdriise. Wiener klin. 
Wochenschr., 1911, Nr. 12. 

Peterson. Value of Pneumo-peritoneal Roentgenography in Obstetrics and 
Gynecology. Jour. Am. Med. Assoc., 1922, lxxviii, 397-400. 

Petri. Neue Probleme des paraenteralen Eiweissabbaues in ihrer Beziehung zur 
Geburtshilfe und Gynakologie. Monatsschr. f. Geb. u. Gyn., 1915, xli, 309-336 
and 388-435. 

Reinl. Ein neues sicheres diagnostisches Zeiclien der Schwangerschaft in den 
ersten Monaten. Prager med. Wochenschr., 1884, Nr. 26. 

Rotter. Ftihlbares Uteringerausch. Archiv f. Gyn., 1873, v, 539-546. 

Sarwey. Zur Diagnostik in der ersten Halfte der Schwangerschaft. Zentralbl. 
f. Gyn., 1904, xxviii, 1156-1163. 

Sciiatz. Klin. Beitrage zur Physiologie der Schwangerschaft. Leipzig, 1910. 
Siegel. Beitrage zur menschlichen Schwangerschaftsdauer. Zentralbl. f. Gyn., 

1921, 984-995. 

Spalding. A Pathognomonic Sign of Intrauterine Death. Surg. Gyn. and Obst., 

1922, xxxiv, 754-757. 

Spiegelberg. Lehrbucli der Geburtshiilfe, III. Aufl., 1891, 126, 127. 

Welz and Van Nest. Sugar Test in Pregnancy. Am. Jour. Obst. and Gyn., 1923, 
v, 33-36. 

Williams and Pearce. Abderhalden’s Biological Test for Pregnancy. Surg. 
Gyn. and Obst., 1913, xvi, 411-418. 

Winckel. Neue Untersuehungen iiber die Dauer der menschlichen Schwanger¬ 
schaft. Volkmann’s Samml. klin. Vortrage, 1901, Nr. 292-293. 

Van Slyke, Vinograd and Loses. The Abderhalden Reaction. J. Biol. Chem., 
1915, xxiii, 377-406. 


CHAPTER VIII 


THE MANAGEMENT OF NORMAL PREGNANCY 

From a biological point of view, pregnancy and labor represent the 
ligliest function of the female reproductive system, and a priori should 
ie considered as a normal process. But when we recall the manifold 
changes which occur in the maternal organism, it is apparent that the 
Dorderline between health and disease is less distinctly marked during 
gestation than at other times, and derangements, so slight as to be of 
but little consequence under ordinary circumstances, may readily be 
the precursors of pathological conditions which may seriously threaten 
the life of the mother or the child, or both. 

It accordingly becomes necessary to keep pregnant patients under 
strict supervision, and to be constantly on the alert for the appearance 
of untoward symptoms. In private practice services of an obstetrician 
should be engaged early in pregnancy, so that upon him devolves the 
duty of advising the patient as to her mode of life during the months 
preceding labor. Any one who has a moderately extensive obstetrical 
practice can save himself no little trouble by having cards printed, 
which briefly outline what the patient is expected to do, and in which 
are enumerated the various abnormal symptoms which may occur and 
to which the physician’s attention should be immediately called. I 
reproduce below (page 231) the card which I give my patients, and 
in the chapter on the conduct of labor the one prepared for the nurse. 

Unless it be found upon inquiry that the patient has been leading an 
ill-ordered existence, very little change should be made in her mode of 
living, and she should be encouraged to go on much as usual, care being 
taken that she receives the proper amount of exercise, amusement, and 
diversion. It is the duty of the physician to gain the confidence of his 
patient and encourage her to come to him whenever anything occurs to 
worry her, instead of taking advice from her women friends. A woman 
in her first pregnancy generally stands in need of a certain amount of 
reassurance with regard to the dangers of parturition, and the know k dge 
that she is in the hands of a competent and careful physician will con¬ 
tribute largely to her peace of mind as well as to her physical well-being. 

One of the few creditable achievements of American obstetrics consists 
in the development of so-called “Prenatal Care.” The term has a wider 
application than the words imply, and may be defined as such super¬ 
vision and care of the pregnant, parturient and puerperal woman as 
will enable her to pass through the dangers of pregnancy and labor with 
the least possible risk, to give birth to a living child, and to be discharged 
in such condition that she may lie able to suckle it and thus afford it 

227 







228 


THE MANAGEMENT OF NORMAL PREGNANCY 


the greatest prospect of attaining maturity, as well as to fulfill her ,j 
duties as mother and housewife with a minimal amount of invalidism. 
In hospital practice the first step in such a program consists in organ- (i 
izing the obstetrical dispensary and indoor service as a single unit. The 
patients should be taught to register early in pregnancy, and to return 
to the dispensary monthly until the seventh month and every two weeks 
thereafter, irrespective of whether they expect to be delivered in the i, 
hospital or in their own homes. At the first visit, in addition to a care¬ 
ful physical examination, a sample of blood should be obtained for the 
Wassermann test, and at each subsequent visit the urine should be 
examined, the blood pressure taken and any other abnormality should be 
detected, with a view to checking it in its incipiency or of admitting the 
patient to the hospital for its relief or cure, if necessary. 

On account of lack of intelligence and indolence many patients will 
fail to follow the directions given unless they are supervised by prenatal 
nurses, and I know of no way in which money can be better expended 
than in providing for this type of care. Those interested in the subject 
will find in the 1915 Transactions of the American Association for 
Study and Prevention of Infant Mortality the report of a committee, 
of which I was Chairman, upon suitable methods of recording prenatal 
work. 

Exercise. —During normal pregnancy the woman should be encour¬ 
aged to take as much outdoor exercise as possible, though in individual 
cases it is often difficult to specify the exact amount—a safe rule being 
to instruct her to desist while still feeling that she could do more without 
tiring herself. Exercise should consist of walking, driving or motoring 
over good roads, but the ordinary sports should be interdicted, though 
in the early months sea bathing is beneficial. When for various reasons 
outdoor exercise cannot be taken, massage in the hands of a skillful 
person is to be recommended. In the later months long journeys should 
not be undertaken unless absolutely necessary, and driving over rough 
roads should be avoided. When possible, the woman should lie down 
for an hour after the mid-day meal. Sleep is not essential, but the 
clothes should be loosened and the mind diverted from its usual channels. 

Among the poorer classes the patients should be cautioned against 
excessive work, especially during the later months, as over-exertion 
has been shown to play an important part in the production of pre¬ 
mature labor. 

Diet.—I n normal pregnancy the diet should be abundant and nour¬ 
ishing, and ordinarily the patient should be allowed to continue her 
usual customs, but should be warned to abstain from very highly seasoned 
or indigestible articles of food. Accordingly, a special diet is not indi¬ 
cated unless some complication, such as toxemia of pregnancy, super¬ 
venes, and the necessary directions will be given under the appropriate 
headings. 

In slight degrees of pelvic contraction, or in patients who have 
previously given birth to excessively heavy children, a restricted diet 
may he advisable during the last two or three months, as I have already 
stated that the larger size of the children in the well-to-do classes is 








SEXUAL INTERCOURSE 


229 


n great part attributable to the life of ease and the abundance of food 
;njoyed by the mothers. Prochownick pointed out that a diet poor in 
:arbohydrates and fluids exerts considerable influence in lessening the 
veight of the child without otherwise affecting it, and these precaution¬ 
ary measures may obviate a difficult delivery. These conclusions stand 
n marked contrast to those usually held by the laity, who erroneously 
)elieve that abstention from proteid food is the essential point. On the 
bther hand, too much should not be expected from such a regime, as 
Experience teaches that it is practically impossible to reduce the weight 
}f the child much below the usual limits. For example, it is well known 
that women in the last stages of tuberculosis frequently give birth to 
well developed, or even fat, children; while Hofmann states that during 
the so-called “hunger blockade” the undernourished German women bore 
children of normal size, but frequently they were unable to suckle them. 
Moreover, the work of Zuntz upon experimental animals demonstrates 
that during pregnancy a diet notoriously defective in one or more of its 
constituents has no effect upon the weight of the offspring, but that 
such undernourished animals are relatively sterile—a conclusion which 
is endorsed by Reynolds and Macomber. 

The Bowels.-—During pregnancy the enlarged uterus sometimes inter¬ 
feres with the normal intestinal peristalsis, and gives rise to more or less 
marked constipation. Under such circumstances care should be taken 
that the bowels are moved daily, which is best accomplished by the ad¬ 
ministration of liquid petrolatum, phenolphthalein, eascara sagrada, 
or pills containing aloin, belladonna, and strychnin. The use of active 
cathartics is inadvisable, unless their employment be specially indicated 
in certain morbid conditions. In some instances, however, the judicious 
administration of an occasional dose of calomel is followed by beneficial 
results. 

Clothing.—The physician is frequently asked concerning the clothing 
which is best adapted to the pregnant state, and especially whether 
corsets should be worn or not. Generally speaking, the clothing should 
be loose and so arranged as to exert as little pressure upon the waist as 
possible; and in the later months of pregnancy, if the patient is ac¬ 
customed to the use of a corset, the ordinary type should be replaced by 
a loosely fitting corset-waist or by one of the specially designed ma¬ 
ternity” corsets. In multiparous women, when the abdomen is markedly 
relaxed from previous childbearing, the wearing of an abdominal sup¬ 
port of elastic material or an ordinary Scultetus bandage adds materially 
to their comfort. When varicose veins of the extremities are present 
the legs should be bandaged or encased in elastic stockings, and when 
large varices exist about the vulva the patient should be cautioned con¬ 
cerning the possibility of their rupture. 

Sexual Intercourse.—In healthy persons sexual intercourse in mod¬ 
eration usually does not harm, as long as the abdominal enlargement 
is not too great to make it inconvenient for the patient. But where 
there is a tendency to abortion or premature labor it should be inter¬ 
dicted. It should also be forbidden in the last month of pregnancy as 
I know of numerous instances in which severe puerperal infection has 






230 


THE MANAGEMENT OF NORMAL PREGNANCY 


followed coitus during that period; and, as the patients had not been 
examined internally but had had sexual intercourse just before the onset 
of labor, it seemed justifiable to attribute the streptococcic infection 
to that cause. 

The Breasts.— In the last months of pregnancy attention should be 
devoted to the condition of the breasts, and more particularly to the 
nipples, as by appropriate preliminary treatment nursing may be ren¬ 
dered easier, and the occurrence of fissures and the consequent danger 

of mammary infection in great part 
prevented. For this purpose the 
patient, during the last two months, 
should anoint her nipples night and 
morning with lanolin or cocoa but¬ 
ter, which tends to render them 
more elastic. When the nipples are 
small it is advisable to attempt to 
lengthen them by making a few 
tractions upon them night and 
morning; and where they are but 
slightly prominent good results 
sometimes follow the wearing of a 
wooden nipple shield (Fig. 193) for a few hours of each day, which is 
held in place by adhesive strips. I know of no means, however, by which 
retracted nipples can be made serviceable. 

Urine. —Owing to the frequency of the toxemias of pregnancy and 
the serious consequences which frequently result from them, the urine 
should be carefully examined at regular intervals: once a month for 
the first seven months, and twice a month, or preferably every week, 
during the last three months of pregnancy. It is advisable that the 
physician should not only arrange definite periods at which specimens 
are to be sent, but that he should himself make a note of these dates, 
so that, in case the patient becomes careless in the matter and neglects 
to carry out his directions, he can remind her. Of course it may be very 
plausibly argued that the patient incurs the main risk from such neglect; 
but the prevention of a single death from eclampsia will amply repay 
the conscientious physician for much self-imposed labor. In hospital 
practice, it is more convenient to procure an absolutely fresh specimen 
each time the patient returns to the prenatal clinic. 

The urine should be examined not only for the presence of albumin 
and sugar, but also microscopically. If more than a trace of albumin 
is detected, the amount should be determined daily by means of Esbaclds 
albuminometer, and whenever it exceeds one-half gram to the liter, 
or symptoms indicative of toxemia are present, the patient should at 
once be put to bed at home or sent into the hospital for observation and 
treatment. 

I 

At each visit the blood pressure should be determined, and in young 
women a systolic pressure of 140 mm. or more should be regarded as a 
danger signal, even though albumin and casts be absent from the urine. 
Moreover, it is advisable to weigh the patient at each visit, as Zange- 




URINE 


231 


meister has shown that any excessive gain in weight may reveal the 
existence of “occult” edema, even before swelling of the face of ex¬ 
tremities becomes apparent, or before the skin pits on pressure. 

In addition to giving the patient the advice above mentioned, the 
physician should also impress upon her the importance of informing him 
at once in case any of the following symptoms be noted: a scanty flow 
of urine, persistent headache, disturbances of vision, swelling of the feet 
and face, any loss of blood no matter how slight, and persistent con¬ 
stipation. In the majority of cases these symptoms are of secondary 
importance, but occasionally they serve to warn us of the imminence 
of some serious affection which may be cured or alleviated by appropriate 
treatment. 


FEINTED DIKECTIONS FOR FRIVATE PATIENTS DURING PREGNANCY 

(a) Take as much outdoor exercise as possible, but guard against 
over-tiring yourself. 

(b) See that the bowels are moved daily. 

(c) On the first day of each month send me a 4-oz. bottle of freshly 
passed morning urine; and for the three months preceding the expected 
date of confinement send it on the first and fifteenth days of the month. 
Be sure to send your name with the specimen. About the same dates 
make an appointment to visit me at my office. 

(cl) From the seventh month onward anoint the nipples night and 
morning with lanolin or cocoa butter in order to render them more 
resistant to the strain of suckling. 

( e) If you expect to be confined at home, buy my “Confinement 
Outfit” six weeks before the expected date. This includes everything 
needed by the nurse and myself, except baby’s clothes. At the same time 
provide two pieces of rubber sheeting, % X 1 yard, and 1X2 yards re- 
| spectively; a bed pan, two small round agate basins, a 2-quart fountain 
syringe and 15 yards of gauze and two pieces of cotton batting for mak¬ 
ing bed pads, or 4 ready-made sanitary bed pads. 

(/) Go to the hospital as soon as labor pains commence, or, if you 
are to be confined at home, send for the nurse, and, unless some 
emergency arises, let her use her judgment in sending for me. 

( g ) Notify me at once if any of the following symptoms be observed 
at any time during pregnancy: 

1. Scanty urine. 

2. Persistent headache. 

3. Disturbance of vision. 

4. Swelling of feet or face. 

5. Loss of blood. 

6. Persistent constipation. 

7. And also when you feel that anything is not as it should be. 

( h) I shall want to see you five or six weeks before you expect to be 
sick in order to ascertain your condition and to give you any desired 
advice. 




232 


THE MANAGEMENT OF NORMAL PREGNANCY 


Preliminary Examination.—In private practice it is not necessary 
to examine the pregnant woman vaginally in the early months of preg¬ 
nancy unless symptoms indicative of some abnormality occur, or unless 
the patient does not expect to be under one’s supervision throughout 
the entire duration of pregnancy. On the other hand, a careful and 
thorough examination is indispensable about six weeks before the ex¬ 
pected date of confinement, and to neglect in this respect can be at¬ 
tributed the deaths of untold numbers of women and children. At this 
time the general condition should be carefully noted, particular attention 
being also pa d to the measurements of the pelvis, as well as to the size, 
presentation and position of the child. 

Unless the physician fully appreciates the importance of this exam¬ 
ination, and has learned to look upon the making of it as a bounden duty, 
he may sometimes be deterred by feeling that it is repugnant to the 
patient, and that she may object to it or even refuse it. My experience, 
however, has always been that a few words of kindly explanation soon 
smooth away all such difficulties; and when, as happens fortunately in 
the vast majority of cases, after the examination we can reassure the 
woman as to the prospects of a simple and safe delivery, she will feel 
amply repaid for any inconvenience to which she may have been sub¬ 
jected. On the other hand, if any abnormality is present, it is essential 
for the physician to know of its existence in advance, and, even although 
he may not always deem it advisable to communicate his conclusions to 
the patient herself, he will do well to inform the husband or some 
other responsible member of her family of the existing condition. If, 
however, despite the exercise of the greatest tact on the part of the 
physician, and his insistence that such an examination is a necessity for 
her own sake, the patient persists in her refusal, the former has no al¬ 
ternative but to decline to have anv further connection with the case. 

«/ 

The first point in the preliminary obstetrical examination is careful 
pelvic mensuration, and Dohrn has well said that the physician who 
neglects pelvimetry is comparable to one who attempts to treat pul¬ 
monary diseases without the aid of auscultation and percussion. In 
the majority of instances the usual external measurements, including 
palpation of the pubic arch, are sufficient, for if these are approximately 
normal and the head is deeply engaged, it will be impossible to measure 
the length of the diagonal conjugate. On the other hand, no matter how 
normal the external measurements may be, the pelvis must be measured 
internally, and if necessary under anesthesia, whenever the head does 
not engage during the last month of a first pregnancy, or in any patient 
in whom the pelvic outlet is contracted, or who limps or presents signs 
of deformity of the spine or legs. Failure to observe this precaution may 
occasionally lead to most unpleasant surprises at the time of labor. If 
an abnormality be detected at this examination the physician is both 
forewarned and forearmed, and in extreme cases he will be prepared to 
interfere at the proper time with every prospect of a successful issue. 

After measuring the pelvis, the abdomen should be carefully ex¬ 
amined, the duration of pregnancy estimated, and the existence of any 
abnormality, as hydramnion or twins, noted; after which the size, position 



LITERATURE 


233 


lid presentation of the child should be determined by external palpation, 
ccording to the rules which will be given later. An internal examina- 
ion should always be made; for, while it is usually not necessary for 
he determination of the presentation and position of the child, it may 
eveal the presence of some abnormality of the generative tract—such 
s an ovarian cyst or a myoma—which might give rise to disastrous 
esults if unrecognized. Furthermore, it is essential when palpation 
ives uncertain or unsatisfactory results, or when the head is not engaged 
u primiparous women or when the patient presents a history of previous 
ifficult labors. The physician who knows how to utilize all the re- 
ources of external palpation and manipulation will find that by these 
aeans he can usually not only recognize normal and abnormal presen- 
ations in advance, but can also convert breech, transverse, or face 
>resentations into those of the vertex. 

When vaginal exploration is necessary at the preliminary examina- 
ion, if undertaken prior to the end of the ninth lunar month, rigorous 
Land disinfection is not necessary, and the physician may content him- 
elf with the use of a nail-brush, soap, and hot water. In the last month 
»f pregnancy, however, the use of a sterile rubber glove is imperative, 
: or we have no means of knowing exactly when labor may supervene, 
md our neglect may occasionally give rise to puerperal infection. 

As will be pointed out in more detail later, one of the most important 
luties of the physician is to bear in mind the possibility of undue pro- 
ongation of pregnancy which may result in the development of a child 
>f excessive size. For this reason, whenever the patient does not fall 
n labor within a few days of the calculated date, she should be examined 
it weekly intervals, and, as soon as the impression is gained that the 
diild has passed the usual limit in size, labor should be induced. 

The various abnormalities occurring in the course of pregnancy will 
De considered in a separate chapter. 

LITERATURE 

Dohrn. Ueber Beckenmessung. Volkmann’s Sammlung klin. Vortrage, Nr. 11. 
Hofmann. Ueber den Einfluss der Kriegskost auf die Geburtsmasse dei Kiiegs- 
neugeborenen. Archiv f. Gyn., 1919, cx, 451-478. 

Prochownick. Ein Versuch zum Ersatze der kiinstlichen Friihgeburt. Zentralbl. 

f. Gyn., 1889, xiii, 577-581. 

Reynolds and Macomber. Certain Dietary Factors in the Causation of Sterility. 
Am. J. Obst. and Gyn., 1921, ii, 379-394. 

Zangemeister. Ueber das Korpergewicht Schwangerer. Zeitschr. f. Geb. u. Gyn., 
1916, lxxviii, 325-365. 

Zuntz. Experimented Untersuchungen liber den Einfluss der ^Ernahrung des 
Muttertieres auf die Frucht. Archiv f. Gyn., 1919, cx, 244-2 io. 






CHAPTER IX 


PRESENTATION AND POSITION OF THE JTETUS—METHODS OF 

DIAGNOSIS 

PRESENTATION AND POSITION OF FCETUS 

Irrespective of the relation which it may bear to the mother, the 
foetus in the later months of pregnancy assumes a characteristic posture, 
which is described as its attitude or habitus; and, as a general rule, it 
may be said to form an ovoid mass, which roughly corresponds with the 
shape of the uterine cavity. It is generally taught that the foetus is 
usually folded or bent upon itself in such a way that the back becomes 
markedly convex, the head is sharply flexed so that the chin is almost 
in contact with the breast, the thighs are flexed over the abdomen, the 
legs are bent at the knee-joints, and the arches of the feet rest upon 
the anterior surfaces of the legs. The arms are usually crossed ovei 
the thorax or are parallel to the sides, while the umbilical cord lies in 
the space between them and the lower extremities. Warnekros, on the 
other hand, contends that the normal habitus is much less constrained, 
and that the contrary view is due to the fact that our conclusions have 
been based upon the study of frozen or hardened specimens, in which 
the uterus is so retracted that it exerts an abnormal pressure upon its 
contents. In his wonderful X-ray atlas, he shows that before the onsel 
of labor the head normally occupies a position midway between flexior 
and extension, the back is but slightly flexed, and the extremities arc 
relatively freely movable—in other words, the foetus is in an uncon¬ 
strained position, analogous to that which it maintains outside of the 
uterus when at rest. 

The attitude is frequently modified by changes in the consistency 
of the abdominal and uterine walls, by the abundance or lack of liquoj 
amnii, as well as by movements of the extremities. Occasionally the 
head may become deflected, when a totally different posture is assumed 
The characteristic attitude results partly from the mode of growth o: 
the foetus, and partly from a process of accommodation between it anc 
the outlines of the uterine cavity. 

Presentation.—By this term is understood the relation which the lon£ 
axis of the foetus bears to that of the mother, and we accordingly dis 
tinguish between longitudinal and transverse presentations. Occasionally 
during pregnancy the foetal may cross the maternal axis at an angle, anc 
thus give rise to oblique presentations; but, as these always become longi 
tudinal or transverse during the course of labor, they ne’ed not be con 
sidered. Longitudinal presentations are by far the most frequent occur 
ring in over 99 per cent, of all cases. 

234 








PRESENTATION AND POSITION OF FCETUS 


235 




Considerable confusion has resulted from confounding the term pres¬ 
entation and presenting part. By the latter we understand the portion 
of the foetus which engages at the superior strait, and is felt through 
the cervix on vaginal examination. Accordingly, in longitudinal pres¬ 
entations the presenting part may he either the head or the breech, and 
we speak of cephalic or breech presentations respectively. When the 


Fig. 194. 
Figs. 194-197.- 


Fig. 195. 


Fig. 196. 


Fig. 197. 


-Showing Difference in Attitude of Fcetus in Vertex, Sinciput, 
Brow, and Face Presentations. 


Fig. 198. Fig. 199. Fig. 200. Fig. 201. 

Figs. 198-201. —Showin- Dii . i in Attitude of Fcetus in Frank Breech, 

Full B .ecu !•• and Knee Presentations. 


foetus lies with its long axis transversely, tlie shoulder is the presenting 
part, and we speak of shoulder presentations. 

Longitudinal - presentations are broadly classified as normal, and 
transverse as abnormal, inasmuch as with the former the child is usually 
delivered by the unaided efforts of Nature; whereas if the latter persist 


it cannot be born spontanco'; > but always requires the aid of the ob¬ 
stetrician. These al .ormal > resentations will be considered in a separate 

chapter. 

Cephalic preset nioj o .* divided into several groups, according to 
the relation which in; ! w trs to the body of the child. Usually the 









236 


PRESENTATION AND POSITION OF THE FCETUS 


\ • • 

head is sharply flexed, so that the chin is in contact with the thorax. 
In these circumstances the vertex is the presenting part— vertex 'presen¬ 
tation. More rarely the neck may be sharply extended, so that the occiput 
and back come in contact and the face engages in the superior strait— 
face presentation. Again, the head may assume an intermediate posi¬ 
tion between these extremes, being partially flexed in some cases, when 
the large fontanel presents— sincipital presentation; or partially ex¬ 
tended in other cases, so that the brow becomes the presenting part— 
brow presentation. The last two are not usually classified as distinct 
varieties, as they are usually transient, and become converted into vertex 
or face presentations as labor progresses. 

When the child presents by its pelvic extremity, the thighs may be 
flexed and the legs extended over the anterior surface of the body— 
frank breech presentation; again, the thighs may be flexed on the abdo¬ 
men and the legs upon the thighs— breech presentation; or the feet may 
be the lowest part— foot or footling presentation. Occasionally one leg 
may retain the position which is typical of one of the above-mentioned 
presentations, while the other foot or knee may present— incomplete foot 
or knee presentation. As the mechanism of labor, however, is essentially 
the same in all modifications of pelvic presentations, the several varieties 
need not be considered separately. 

Position.—By this term we designate the relation of some arbitrarily 
chosen portion of the child to the right or left side of the mother. Ac¬ 
cordingly, with each presentation we have one or other of two positions—- 
right or left. With us and in France, the occiput, chin, and sacrum are 
the determining points in vertex, face, and breech presentations re¬ 
spectively; while in Germany the child’s back is the orienting portion. 

Variety.—Furthermore for the purpose of still more accurate orien¬ 
tation, we take into consideration the relationship of some gi ven po rtion 
of the presenting part to the anterior, transverse, or posterior portion of 
the mother’s pelvis. Thus, as there are two positions, there will be in all 
six varieties for each presentation. But as the transverse varieties usu¬ 
ally represent only a phase in the mechanism of labor, and are not per¬ 
sistent, they need not be taken into account. 

Nomenclature.—Unfortunately, a universal nomenclature for desig¬ 
nating the various presentations and positions has not as yet been agreed 
' upon, and the methods employed vary in different countries and even in 
different parts of the same country, though of late there has arisen a 
greater tendency toward uniformity. 

In the earlier works upon obstetrics, as in Roesslin’s Rosengarten 
(1513), it was believed that the child might assume any imaginable posi¬ 
tion in utero, and the number of presentations and positions was limited 
only by the ingenuity of the writer. More accurate observation gradually 
did away with the fanciful forms, but even as late as 1775 Baudelocque 
distinguished 94 different presentations. Mme. La Chapelle (1821) ma¬ 
terially simplified the subject, and the classification which she suggested 
differs but little from that employed in France to-day, which has been 
best described by Farabeuf and Varnier. 

According to the French method, vertex, face, and breech presenta- 








PRESENTATION AND POSITION OF FCETUS 


237 


tions are designated as occipito-iliac (0. I.), mento-iliac (M. I.), and 
sacio-iliac (S. I.). At the International Medical Congress which met in 
M ashington in 1887 an attempt was made to secure greater uniformity 
in nomenclature, when it was suggested that the denomination “iliac” 
be omitted and the various presentations designated as occipital, mental, 
and sacral respectively. The suggestion was quite generally accepted in 
Ameiica and Great Britain, and Bar in 1903 advocated its universal 
adoption. 

As the presenting part in any presentation may be either in the left 
or right position, we have left and right occipital, left and right mental, 
and left and right sacral presentations, which in an abbreviated form 
may be written L. 0. and R. 0., L. M. and R. M., L. S. and R. S. 
Again, as the presenting part in each of the two positions may be di¬ 
rected anteriorly, transversely, or posteriorly, we may have six varieties 
of each presentation. Thus, we have the classification given on'the 
following page. 

In Germany considerable confusion exists, as the various authorities 
still employ different classifications. Thus Schroeder, Olshausen and 
\eit did not distinguish variety at all, and they designated the position 
according to the situation of the back of the child, speaking of first and 
second positions according as the back is directed to the left or right 
side of the mother respectively. Others employ a different nomenclature, 
and designate our L. 0. A., R. 0. A., R. 0. P., and L. 0. P. as first 
second, third, and fourth positions respectively. The exhaustive articles 
of Muller and Schatz deal fully with this subject. 

Our nomenclature presents many advantages over the German, as 
it is based upon the relation of the presenting part to the maternal pelvis, 
and enables one to describe with accuracy the situation of the former 
at any period of labor. 

Frequency of the Various Presentations and Positions.—According 
to the statistics collected by Schroeder, based upon several hundred thou¬ 
sand cases, the vertex presents in 95 per cent., the face in 0.6 per cent., 
and the breech in 3.11 per cent., transverse presentations occurring in 
only 0.56 per cent, of all cases. Markoe, in fifty-one thousand deliveries 
occurring in the New York Lying-in Hospital, noted 94.2, 0.48, 3.9, and 
s 0.9 per cent., respectively, while in the first seventy-five hundred admis¬ 
sions to the obstetrical service of the Johns Hopkins Hospital the in¬ 
cidence of the several presentations was 94.6, 0.34, 3.9, and 0.96 per cent., 
respectively. These figures apply to the conditions observed at or near 
full term, but prior to the seventh month breech and transverse presen¬ 
tations occur more frequently. 

It is usually stated that about 70 per cent, of all vertex presentations 
occur in the left, and only 30 per cent, in the right position, and we 
have found 64 and 36 per cent., respectively. Schatz has shown that the 
former becomes more and the latter less frequent the nearer preg¬ 
nancy approaches term. Naegele first pointed out that the occiput was 
usually directed anteriorly in left, and posteriorly in right positions; 
so that it is usually found at one or other extremity of the right oblique 
diameter of the pelvis, owing to the fact that the left oblique di- 






238 


PRESENTATION AND POSITION OF THE FCETUS 




Fig. 202 


Fig. 203. 



Position. 

Presentation. 

Variety. 

Abbreviation. 

Vprfpv nrpspntations. 

Left. 

< i 

i ( 

Right. 

i i 

i ( 

Occipital. 

i ( 

( C 

< i 

l i 

l ( 

Anterior. 

Transverse. 

Posterior. 

Anterior. 

Transverse. 

Posterior. 

L.O.A. 

LOT. 

LOP. 

R.O.A. 

R.O.T. 

R.O.P. 



Figs. 202, 203. —Showing Varieties of Vertex Presentations. 


Face presentations. 


Left. 
< < 


Right. 
( ( 

( ( 


Mental. 


Anterior. 

Transverse. 

Posterior. 

Anterior. 

Transverse. 

Posterior. 


L.M.A. 

L.M.T. 

L.M.P. 

R.M.A. 

R.M.T. 

R.M.P. 


Fig. 204. Fig. 205. 

Figs. 204, 205. —Showing Varieties of Face Presentations. 

Breech presentations... 


Left. 

Sacral. 

Anterior. 

< < 

1 ( 

Transverse. 

< < 

i i 

Posterior. 

Right. 

< < 

i ( 

Anterior. 

< < 

Transverse. 

t ( 

( ( 

Posterior. 


L.S.A. 

L.S.T. 

L.S.P. 

R.S.A. 

R.S.T. 

R.S.P. 


Fig. 206. 


Fig. 207. 


Figs. 206, 207. —Showing Varieties of Breech Presentations. 

























PRESENTATION AND POSITION OF FCETUS 239 

ameter is materially encroached upon at its posterior extremity by the 
rectum. ' ' 

Reasons for the Predominance of Head Presentations.—Hippocrates 
recognized the overwhelming frequency of head presentations at the end 
of pregnancy, but believed that the child presented by the breech up tq 
the seventh month, when it suddenly turned and presented by the head, 
the process being often expressed by the French term culbute. 

As a result of the more frequent examination of pregnant women, 
the error of the Hippocratic teachings was gradually demonstrated, so 
that fiom the time of Smellie and Baudelocque it was generally believed 
that head presentations predominated throughout all periods of preg¬ 
nancy, but became more frequent in the later months. For many years 
it v as taught that the presentation remained constant throughout preg¬ 
nancy, and it was not until 1861 that Hecker and Schultze demonstrated 
that it was not unusual for changes of position to occur even in the 
later months. How it is universally admitted that the presentation does 
not become definitely established until the presenting part enters the 
pelvic canal, although it becomse more and more stable the nearer full 
term is approached. 

The theories put forward to account for the prevalence of head pres¬ 
entations are divided into two groups, the one being based upon gravi¬ 
tation, the other supposing a process of accommodation between the 
foetus and the uterine cavity. 

The gravitation theory was especially advocated by Matthews Duncan 
and G. Veit, both of whom showed that a foetus recently dead, when 
placed in a vessel containing a solution of salt having about the same 
specific gravity as itself (1.059-1.055), floated with its head and right 
side downward. This result they attributed to the greater specific 
i avity of the head, together with the presence of the liver on the right 
side. A r eit also showed that head presentations increase in frequency 
with the advance of pregnancy, but that breech presentations were noted 
much more frequently when the child was dead. This he attributed to the 
fact that the specific gravity of the head became diminished after death. 

Furthermore, it was pointed out that since the axis of the uterus, 
with the woman in the upright position, forms an angle of about 35 
degrees with the horizon, the head would necessarily sink downward, 
and the convex back of the foetus would adapt itself to the concave 
anterior wall of the uterus; then, since the organ is usually so rotated 
about its long axis that its left margin is directed somewhat forward, 
the frequency of the left anterior presentations could be readily ex¬ 
plained. Schatz in 1904 showed that this tendency was increased under 
the influence of gravity. This he demonstrated by examining a series of 
women in the morning before arising, and again in the evening after 
they had been about all day, when he found that the anterior varieties 
of vertex presentations occurred more frequently in the evening. Warne- 
kros has still further emphasized, by means of X-ray photographs, the 
part played by gravity by showing that a vertex could be converted 
into a breech presentation by placing the woman in the Trendelenburg 
posture, thereby reversing the direction in which gravitation acts. 


240 


PRESENTATION AND POSITION OF THE FCETUS 


In 1900 doubt was cast upon the conclusions of Duncan and A eit by 
Scliatz, who maintained that, although their results were correct when 
experimenting with a medium of the same specific gravity as the foetus, 
it does not necessarily follow that they hold good for the amniotic 
fluid, which, it must be remembered, possesses a specific gravity of be¬ 
tween 1.008 and 1.009, or considerably less than that of the foetus. 
Schatz suspended a recently dead foetus by the head and breech from the 
pans of a balance in a solution of salt of the same specific gravity as the 
amniotic fluid, and found that the breech had a greater tendency to sink 
down than the head; but, as the specific gravity of the fluid was gradu¬ 
ally increased, the breech slowly rose until the long axis of the child 
became horizontal, and, as a density of 1.050 was approached, the head 
sank down as in Duncan’s experiment. He therefore concluded that 
gravity alone does not account for the production of head presentations; 
for, if ii were the most important factor concerned, breech presentations 
would predominate at the end of pregnancy. As this is not the case, 
some other influence must be invoked to explain the prevalence of the 
former. Seitz repeated this work, and upon determining the specific 
gravity of the head and body of the foetus, separately, found that the 
former was relatively lighter than the latter in the first eight months, 
but heavier in the last two months of pregnancy. Consequently, he 
concluded that gravity could account for the predominance of head 
presentation only in the latter period. Furthermore, as the specific 
gravity was identical whether the foetus were macerated or normal, and 
yet breech presentations were noted much more frequently in the former 
condition, he held that some other factor must be concerned. 

This is supplied by the theory of accommodation, advanced by Du¬ 
bois, Simpson, and Scanzoni, according to which cephalic presentations 
are brought about by a process of accommodation between the foetal 
ovoid and the interior of the uterine cavity, the shape of the latter being 
such that the foetus is most comfortable and fits it most accurately 
when presenting by the head. They held, therefore, that as soon as the 
foetus came to occupy any other position its cutaneous surface became 
irritated, whence resulted reflex movements of the extremities, giving 
rise in turn to uterine contractions, which tended to restore the head 
presentation. Pinard and Sellheim are enthusiastic advocates of this 
theory; and the latter has indicated that but little force is needed to 
bring about such movements, as for practical purposes, the weight of 
the foetus is almost negligible, being represented merely by the difference 
between its specific gravity and that of the amniotic fluid. 

The frequency of abnormal presentations in the early months of preg¬ 
nancy, and in all conditions in which the uterus is abnormally distended 
by an excess of amniotic fluid, tends to substantiate the accommodation 
theory; for in such cases the body of the child does not come in contact 
with the uterine walls, and accordingly the conditions necessary for the 
production of the reflex movements, which give rise to accommodation, 
arc entirely lacking, and gravity alone comes into play. 

The subject was again taken up in 1915 by Barnum in this country 
and by Griffith in Great Britain, with the result that, while they were able 


DIAGNOSIS OF PRESENTATION AND POSITION OF FGETUS 241 


to confirm the observations of Schatz and Seitz, they held that they had 
failed to take into consideration all the factors concerned, and that their 
conclusions were therefore untenable. Both of the former investigators 
found in the last two months of pregnancy that the specific gravity of 
the head is greater than that of the body, but that, in the usual intra¬ 
uterine habitus, the center of gravity of the entire foetus lies slightly 
nearer the breech than the head, while the center of buoyancy, or the 
metacenter, is situated still nearer the breech. Consequently, as the 
latter must lie above the former in order for the foetus to float in an 
approximately vertical direction, the head must descend. Furthermore, 
as Griffith estimates that the effective weight of the foetus is only 150 
or 200 grams, it may readily be admitted that while gravity is the main 
factor involved, the process of accommodation may play an important 
part in causing changes in the position of a body presenting so slight an 
effective weight. 

Notwithstanding the very considerable amount of research which 
has been done upon the subject, I do not believe that the final word has 
been spoken, and I would refer those interested to the articles of Barnum 
and Griffith, and to the monograph of Cohnstein published in 1868 for 
information concerning the various older theories. 


DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 

The diagnostic methods at our disposal are fourfold: 'abdominal 
palpation, Vaginal and rectal touch/ combined examination, and auscul¬ 
tation, and in certain doubtful cases the X-ray. 

Obstetrical Palpation. —Under ordinary circumstances external or 
abdominal palpation is the most reliable and valuable, and I should 
unhesitatingly choose it were I restricted to the employment of a single 
method of examination. In trained hands it enables one to make a 
satisfactory diagnosis without danger of infection and with the least 
possible discomfort to the patient, and it is not going too far to say that 
its popularization forms one of the greatest advances in modern ob¬ 
stetrics. Accordingly it behooves the student to become thoroughly 
familiar with the proper technic, and to avail himself of every oppor¬ 
tunity to become proficient in the various manipulations. 

Although crude forms of abdominal palpation had no doubt been 
practiced from the earliest antiquity, just as they are still employed by 
many of the aboriginal peoples, its advantages were first pointed out by 
Roederer, Wigand, and Hohl, as late as the lattei pait of the eighteenth 
and the early part of the nineteenth century. Its practical importance, 
however, was not generally recognized until 1818, when Pinard published 

his work upon the subject, after which the method became popularized 

. 1 until Crede 

i should be 

made systematically bv following the four maneuvers suggested by Leo¬ 
pold. The patient should be on a hard bed or examining table, with 


in France, but was not employed systematically eisewne 
and Leopold had repeatedly urgjed its value. 

Tn order to obtain satisfactory results, the examina 




242 


PRESENTATION AND POSITION OF THE FCETUS 


the abdomen bared, or at most covered with a thin chemise. During 
the first three maneuvers the examiner stands at the side of the bed 
which is most convenient to him, and faces the patient, but reverses his 
position and faces her feet for the last maneuver (see Plates XI to XIV). 

First Maneuver .—After outlining the contour of the uterus, and 
determining how nearly its fundus approaches the xiphoid cartilage, the 
fundus is gently palpated with the tips of the fingers of the two hands, 
and the foetal pole occupying it differentiated, the breech giving the 
sensation of a large, irregularly shaped, nodular body, and the head 
that of a hard, round object, which is freely movable and ballottable. 

Second Maneuver .—Having determined which pole of the foetus lies 
at the fundus, the examiner places the palmar surface of his hands on 
either side of the abdomen and makes gentle but deep pressure. On one 
side he feels a hard resistant plane—the back—and on the other numer¬ 
ous nodulations—the small parts. In women with thin abdominal walls 
the legs and arms can readily be differentiated, but in fat persons only 
irregular nodulations can be felt. In the latter case, or when a consid¬ 
erable quantity of amniotic fluid is present, the appreciation of the back 
can be facilitated by making deep pressure with one hand while palpat¬ 
ing with the other. After determining upon which side the back is 
situated, we next note whether it is directed anteriorly, transversely, or 
posteriorly, and thereby gain an exact idea of the orientation of the 
body. 


Third Maneuver .—The examiner grasps the lower portion of the 
abdomen, just above the symphysis pubis, between the thumb and fingers 
of one hand, and decides what is between them. If the presenting 
part be not engaged, a movable body will be felt, which is usually the 
head. The differentiation between it and the breech is made as at the 
fundus, the former being appreciated as a hard, round, ballottable body. 
If the presenting part be not engaged, this practically completes the 
examination, as we now know the situation of the head, breech, back, and 
extremities, and all that remains is to determine the attitude of the head. 
If careful palpation shows that the greatest cephalic prominence is on 
the same side as the small parts, we know that the head is flexed and 
that the vertex is the presenting part; but when the reverse is the case 
we know that the head is extended and that we have a face presentation. 
On the other hand, if the presenting part is deeply engaged, this 
maneuver simply shows that the lower pole of the foetus is fixed in the 
pelvis, and the details concerning it are ascertained as follows: 

Fourth Maneuver .—The examiner faces the patient’s feet, and with 
the tips of the first three fingers of each hand makes deep pressure in the 
direction of the axis of the superior strait. If the head presents, he finds 
that one hand is arrested sooner than the other by a rounded body—the 
cephalicprominence; while the other hand descends deeper into the 
pelvis. In vertex presentations the prominence is on the same side as the 
small parts, and in face presentations on the same side as the backTI 
Again, the degree of ease with which the prominence is felt indicates the 
extent to which descent has occurred. In manv instances, when the 

«, y 

head has descended into the pelvis, the anterior shoulder of the child 





DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 243 

can be readily differentiated by the third maneuver. In breech presen¬ 
tations the information obtained from this maneuver is not so definite 
as in head presentations. 

I his method of examination is available throughout the later months 
of pregnancy, and in the intervals between the pains at the time of labor. 
By its use we can not only determine the presentation and position of 
the child, but also obtain important information as to the extent to 
which the presenting part has descended into the pelvis, and we know 
when the cephalic prominence can no longer be palpated from above 
that the head has descended so deeply that its most dependent part 
can be palpated through the pelvic floor. Moreover, when there is dis- 
propoition between the size of the head and the pelvis, its seriousness 
can be gauged by determining the extent to which the anterior portion 
of the head overrides the symphysis pubis. Likewise, with practice, 
it is possible to estimate roughly the size of the child, while in twin 
pregnancy the second foetus can be mapped out. 

During uterine contractions, on carefully palpating in the region of 
the internal abdominal ring, one can often distinguish a rounded cord 
on either side—the round ligaments —from which important information 
may be obtained. In the first place, the intensity of their contraction 
gives some idea of the manner in which the uterus is acting; and sec¬ 
ondly, by noting their course, as pointed out by Palm and Leopold, it is 
possible to diagnose the situation of the placenta in about 88 per cent, 
of all cases. When the round ligaments are found converging to’ward 
the fundus of the uterus, the placenta is usually situated upon the pos¬ 
terior wall, whereas it is upon the anterior wall when they are parallel 
or diverging. 

During labor, palpation also gives us valuable information concerning 
the lower uterine segment; when there exists some obstruction to the 
passage of the child, the contraction ring may be felt as a transverse or 
oblique ridge extending across the lower portion of the uterus. More¬ 
over, in normal cases, w T e can differentiate by palpation between the con¬ 
tracting body of the uterus and the passive lower uterine segment; for 
during a pain the former presents a firm, hard sensation, while the latter 
appears elastic and almost fluctuant. 

Vaginal Examination.—During pregnancy the results arrived at by 
vaginal examination, concerning the presentation and position of the 
child, are necessarily somewhat inconclusive, for, as the cervix is still 
closed, one is obliged to palpate the presenting part through the lower 
uterine segment. During labor, on the other hand, after more or less 
complete dilatation of the cervix, important information may be obtained. 
In vertex presentations the position and variety are determined by the 
differentiation of the various sutures and fontanels; in face presen¬ 
tations, by the differentiation of the various portions of the face; and 
in breech presentations, by the palpation of the sacrum and ischial 
tuberosities. 

Under the most favorable circumstances the information to be de¬ 
rived from vaginal touch alone is not more accurate than that obtained 
by abdominal palpation, and in vertex presentations the fontanels are 


244 


PRESENTATION AND POSITION OF THE FCETUS 


frequently mistaken for one another; and occasionally face and breech 
presentations escape differentiation. Moreover, later in labor, after the 
formation of the caput succedaneum, detection of the various diagnostic 
points often becomes impossible. 



Fig. 208. —Diagram showing Method of Locating Sagittal Suture on Vaginal 

Examination. 

A much more serious objection, however, is the danger of puerperal 
infection, no matter how careful one's technic may be; for it is now 
irenerallv admitted that absolute hand disinfection cannot be effected, 

O J 



Fig. 209. —Diagram showing Method of Differentiation between the Fontanels 

and, even granting that the use of sterile rubber gloves overcomes this 
difficulty, the gloved fingers may still carry up into the vagina pathogenic 
microorganisms from the margins of the vulva, and thus give rise to 
infection. 









DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 245 

Accordingly, it is advisable to limit vaginal examination as much 
as possible, and in normal cases to do away with it altogether. For 
if the preliminary examination has shown that the patient has a normal 
pelvis, and presents no other abnormality, and we find by the fourth 
maneuver that the head is deeply engaged, all that we gain by vaginal 
examination is information as to the degree of dilatation of the cervix, 
and the condition of the membranes, and this can usually be ascertained 
equally well by rectal examination. Accordingly, vaginal examination 
becomes absolutely necessary only in the few cases in which palpation 
and rectal examination do not give satisfactory results, or in patients 
presenting some abnormality, or in whom the course of labor is unduly 
delayed. Personally, I conduct the great majority of my private cases 
in this manner, and ordinarily do not make a vaginal examination until 
about to discharge the patient. 

In attempting to determine the presentation and position by vaginal 
examination, it is advisable to pursue a definite routine, which is readily 
accomplished by three maneuvers. 

First Maneuver .—After appropriate preparation of the patient, two 
fingers of either the right or left gloved hand, as best suits the examiner, 
are introduced into the vagina and carried up to the presenting part. 
A few moments suffice to determine whether it is a vertex, face, or 
breech. 

Second Maneuver .—If the vertex be presenting, the fingers are car¬ 
ried up behind the symphysis pubis, and are then swept backward over 
the head toward the sacrum. During this movement they necessarily 
cross the sagittal suture. When it is felt, its course is outlined, and we 
know that the small fontanel must lie at one and the large fontanel 
at the other end of it. 

Third Maneuver .—We then attempt to determine the position of the 
two fontanels. For this purpose the fingers are passed to the anterior 
extremity of the sagittal suture, and the fontanel there encountered is 
carefully examined and identified; then, by a circular motion, the fingeis 
are passed around the side of the head until the other fontanel is felt 
and differentiated. By this means the various sutures and fontanels 
are readily located, and the possibility of error is considerably lessened. 
In face and breech presentations it is still further minimized, as the 

various parts are more readily distinguished. 

Combined Examination.—By combined examination we understand 
the introduction of two fingers of one hand into the vagina, and the 
application of the other hand over the lower portion of the abdomen. 
This method is rarely employed except when the presenting part is not 
engaged, and the external hand is used to fix it so as to permit the in¬ 
ternal fingers to explore it satisfactorily. 

Auscultation.—By itself, auscultation does not give very important 
information as to the presentation and position of the child, but it some¬ 
times reenforces the results obtained by palpation. Ordinarily, the heart 
sounds are transmitted through the convex portion of the foetus, which 
lies in intimate contact with the uterine wall. Accordingly they are 
heard loudest through the back in vertex and breech, and through t le 



246 


PRESENTATION AND POSITION OF THE FCETUS 


thorax in face presentations. The region of the abdomen in which the 
foetal heart is heard most plainly varies according to the presentation and 
the extent to which the presenting part has descended. In head presen¬ 
tations the point of maximum intensity is usually midway between the 
umbilicus and the anterior superior spine of the ilium, while in breech 
presentations it is usually about on a level with the umbilicus. 

Auscultation frequently gives us not a little supplementary aid in de¬ 
termining the position of the child. Thus, in occipito-anterior presenta¬ 
tions the heart is usually best heard a short distance from the middle 
line; in the transverse varieties it is heard more laterally, and in the 
posterior varieties well back in the patient’s flank. Occasionally, how¬ 
ever, in obliquely posterior positions, the information gained from the 
location of the foetal heart is misleading, and may give rise to serious 
diagnostic errors; for if the flexion of the head be imperfect, the thorax 
may become convex, in which event the heart sounds may be trans¬ 
mitted through it and lead one to suppose that one has to deal with 
an obliquely anterior/ position. 

LITERATURE 

Bar. Rapport sur 1 ’unification de la nomenclature obstetricale. L ’obstetrique, 
1903, viii, 103-114. 

Barnum. The Effect of Gravitation on the Presentation and Position of the 
Foetus. J. Am. Med. Assn., 1915, lxiv, 498-502. 

Baudelocque. L ’art des accouchements. Paris, 1789, 2me ed. 

Cohnstein. Die Aetiologie der normalen Kinderlagen. Monatssclir. f. Geburtsk., 
1868, xxxi, 141-193. 

Crede. Gesunde und kranke Wochnerinnen. Leipzig, 1886, 80-81. 

Crede und Leopold. Die geburtshiilfliche Untersuchung. Leipzig, 1892. 

Dubois. Memoire sur la cause des presentations de la tete. Mem. de 1 ’Acad, de 
med., 1833, ii. 

Duncan. The Position of the Foetus. Researches in Obstetrics, Edinburgh, 1868, 
14-37; also Edinburgh Med. and Surg. Jour., 1855. 

Farabeuf et Varnier. Introduction a 1 ’etude clinique et a la pratique des ac¬ 
couchements. Paris, 1904. 

Griffith. An Investigation of the Causes which Determine the Lie of the Foetus 
in Utero. Jour. Obst. and Gyn. Brit. Emp., 1915, xxvii, 105-123. 

Hecker. Klinik der Geburtshiilfe. Leipzig, 1861, i, 17. 

Statistisches aus der Gebaranstalt Munchen. Archiv f. Gyn., 1882, xx, 378-398. 
Hohl. Die geburtshiilfliche Exploration. Halle, 1834, ii, 144-166. 

International Medical Congress. Uniformity in Obstetrical Nomenclature. 

Amer. Jour. Obst., 1889, xx, 1084-1086. 

La Chapelle, Madame. Pratique des accouchements. Paris, 1821, i, 17-25'. 
Leopold. Die Diagnose des Placentarsitzes in der Schwangerschaft und wahrend 
der Geburt. Arbeiten aus der Dresdener Frauenklinik, 1895, ii, 151-166. 
Leopold und Sporlin. Die Leitung der regelmassigen Geburten nur durch aussere 
Untersuchung. Archiv f. Gyn., 1894, xlv, 337-368. 

Markoe. Observations and Statistics on Sixty Thousand Labors, etc. Bull, of 
the Lying-in Hospital of the City of New York, 1909, vi, 101-115. 

Muller, A. Ueber die Ursachen der Ungleichheit und Unklarheit in der Benen- 
nung und Eintheilung der Kindeslagen. Monatsschr. f. Geb. u. Gyn., 1900, 
xii, 161-181; 266-291. 


LITERATURE 


247 


Naegele. Die Lehre vom Mechanismus der Bebnrt. Mainz, 1838, 10. 

Palm. Ueber die Diagnose des Placentarsitzes in de.r Sehwangerschaft, etc. Zeit- 
schr. f. Geb. u. Gyn., 1893, xxv, 317-350. 

Pinard. L ’accommodation fcetale. Traite du palper abdominal. Paris, 1878. 

Roederer. Elementa artis obstetricia?. Goettingse, 1766. 

Scanzoni. Lage und Haltung des Kindes in der Gebarmutter. Lehrbuch der 
Geb., II. AufL, Wien, 1853, 89-93. 

Schatz. Ueber den Schwerpunkt der Frucht. Zentralbl. f. Gyn., 1900, Nr. 40, 
1033-36. 

Die Ursachen der Ivindeslagen. Archiv f. Gyn., 1904, Ixxxi, 541-651. 

Schroeder, Olshausen und Veit. Lehrbuch der Geburtshiilfe, XIII. Aufl., 
1899. 

Sciiultze. Untersuchungen iiber den Wecksel der Lage und Stellung des Kindes 
in den letzten Wochen der Sehwangerschaft. Leipzig, 1861. 

Seitz. Ueber den Einfluss der Schwerkraft auf die Entstehung der Schadellageu. 
Archiv f. Gyn., 1908, lxxxvi, 114-144. 

Sellheim. Exp. und vergleichend physiologische Untersuchungen liber die Ent- 
wicklung der typischen Fruchtlage. Archiv f. Gyn., 1917, evi, 1-57. 

Simpson. Attitude and Positions of the Foetus in utero. Monthly Journal of 
Med. Sciences, 1848-49, ix, 423; 639; 863. 

Smellie. A Treatise on the Theory and Practice of Midwifery. 8th ed., London, 
1774. 

Veit, G. Die Lagenverhaltnisse bei Friih- und Zwillingsgeburten. Scanzoni’s 
Beitrage, 1860, iv, 279-292. 

Warnekros. Schwerkraft und Kopflage. Archiv f. Gyn., 1919, cxi, 21-28. 

Sehwangerschaft und Geburt im Roentgenbilde. Miinchen, 1921. 

Wigand. Die Geburt des Mensehen. Berlin, 1820, ii, 99. 


SECTION IV 


PHYSIOLOGY OF LABOR 
CHAPTER X 

THE PHYSIOLOGY AND CLINICAL COUESE OF LABOE 

By labor we understand the process which brings about the separation 
of the mature or nearly mature product of conception from the interior 
of the uterus, and its extrusion from the maternal organism, whether 
the birth occurs spontaneously or requires external aid. 

Cause of the Onset of Labor.—From time immemorial inquiring 
minds have sought an explanation for the fact that labor usually ensues 
about two hundred and eighty days after the appearance of the last 
menstrual period, but thus far no satisfactory universal cause has been 
discovered. The following are among the most important theories which 
have been advanced as to its causation: 

1. The growing irritability of the uterus, associated with an increase 
in the frequency and strength of the intermittent contractions. 

2. Increasing distention of the uterus. 

3. Dilatation of the cervix by the presenting part. 

4. Increasing distention of the lower uterine segment, with pressure 
upon the neighboring nervous structures. 

5. Changes in the decidua—loosening, thinning, and thrombosis. 

6. Excess of carbon dioxid or lack of oxygen in the placental blood, 
acting on nervous centers. 

7. The circulation of foetal metabolic products acting upon similar 
centers. 

8. Menstrual periodicity. 

9. Anaphylactic action of foetal blood. 

10. Heredity and habit. 

11. Senility of the placenta. 

12. Physical and emotional causes. 

1. The increasing readiness with which the uterus reacts to stimula¬ 
tion during the later months of pregnancy affords abundant evidence of 
its growing irritability. The intermittent contractions, which occur at 
intervals throughout pregnancy, come on more frequently at this time, 
and occasionally with such intensity that it may be difficult, in the last 
few weeks before delivery, to distinguish between them and actual labor 
pains. 

2. Since the time of Mauriceau it has been believed that the uterus, 
when distended up to a certain point, must begin to contract and attempt 

248 


CAUSE OF THE ONSET OF LABOR 


249 


to empty itself, just as happens in the case of any other hollow viscus. 
This presumption is supported by the frequency with which premature 
labor occurs in hydramnion or twin pregnancies. On the other hand, 
extreme distention does not necessarily give rise to labor, as is shown by 
the cases of prolonged pregnancy which are associated with large children. 

3. Galen supposed that labor resulted from gradual dilatation of the 
cervix, which was brought about by the pressure of the presenting part, 
and the view still has numerous adherents. That the condition of the 
cervix is not the sole factor is shown by the fact that occasionally con¬ 
siderable dilatation may exist for days or even weeks before the onset 
of labor. 

4. Keilmann and Kniipffer advanced the theory that the onset of 
labor was the result of the gradual formation of the lower uterine 
segment, with consequent pressure upon the surrounding nervous ganglia. 
Their work was done upon the bat, and was quite convincing so far as 
that animal is concerned, but it is questionable whether identical factors 
are concerned in human beings. 

5. Naegele, Simpson, Scanzoni, and others believed that the decidua 
in the later weeks of pregnancy underwent fatty degeneration, which 
resulted in the partial separation of the ovum and its practical conversion 
into a foreign body, which then gave rise to uterine contractions. More 
recent investigations, however, have shown that such changes do not 
occur normally. 

It is generally recognized that the septa, by which the glandular 
spaces of the spongy layer of the decidua are bounded, become progres¬ 
sively thinner in the later months of pregnancy, and some authorities 
assume that in the last few weeks they tend to rupture and thereby 
bring about more or less extensive separation of the ovum from the 
uterine wall. No conclusive evidence of such an occurrence has been 
adduced, and my experience, which is based upon the examination of a 
considerable number of uteri at or near term, indicates that as a rule 
the septa are not torn through until the third stage of labor. 

6. Brown-Sequard in 1853 demonstrated that an excess of carbon 
dioxid in the blood led to energetic uterine contractions, and his state¬ 
ments have been confirmed by most subsequent investigatois (Keiffei). 
Even if this be true, no one has as yet adduced evidence of a sudden 
increase in the amount of carbon dioxid in the blood sufficient to give rise 
to labor at the appointed time; although Leopold and others have con¬ 
tended that the carbon dioxid content of the placental blood is maikedl) 
increased as a result of progressive thrombosis of the decidual vessels. 

My own investigations, however, lead me to believe that such a con¬ 
tention is based upon uncertain foundations; for, while pronounced 
thrombosis may sometimes be demonstrated, it is lacking in most full- 
term uteri On the other hand, it occasionally develops early in preg¬ 
nancy without leading to its interruption. For these reasons, I believe 
that the last word has not yet been spoken concerning the striking 
vascular changes which occur in the decidua basalis. Moreover, recent 
work tends to invalidate Brown-Sequard’s conclusions. Blumreich holds 
that carbon dioxid has less effect upon the pregnant than upon the non- 


250 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR 


pregnant uterus, while Kurdinowsky and Kehrer contend that it does 
not give rise to contractions at all. 

7. Spiegelberg advanced the view that the onset of labor is due to 
foetal rather than maternal changes. He considered that the mature 
foetus needs materials for its sustenance other than those furnished by 
the placenta, and that as a result of insufficient nutrition certain excre- 
mentitious substances gain access to the maternal circulation, and in 
some w'ay stimulate the uterus. 

The observations of Kurdinowsky upon the isolated uterus, of Kehrer 
upon the extirpated living uterus, of Kruieger and Offergeld upon the 
uterus separated from all connection with the central nervous system, 
of Sauerbruck and Heyde in symbiotic experiments, as v r ell as various 
metabolic studies, tend to indicate that the ultimate cause of labor must 
be sought in some substance or substances circulating in the maternal 
blood. We are profoundly ignorant of the nature of this hypothetical 
substance, and do not know wdiether it is derived from the foetus, the 
ovaries, or the general organism of the mother, although certain evidence 
points toward the former. 

In the experimental observations of Kruieger and Offergeld, in 
which the uterus w r as cut off from all connection with the central nervous 
system, labor set in at the usual time and progressed normally. Accord¬ 
ingly, it must be admitted that the process is not necessarily dependent 
upon the stimulation of centers situated in the central nervous system, 
but must be attributed to the stimulation of the intra-uterine ganglia 
by substances brought to the uterus either by the circulating blood, 
or originating in the fcetus itself. Furthermore, the experiments of 
Sauerbruck and Heyde, which I have been able to confirm to some 
extent, point to a similar conclusion. These investigators united rats 
to one another in such a manner that they continued to live in symbiosis, 
and, if both animals were pregnant, they found that the occurrence of 
labor in one set up a similar process in the other; whereas, if only one 
were pregnant, the onset of labor w^as associated with serious illness on 
the part of the non-pregnant animal. Such observations indicate that 
the cause of labor must be sought in the circulation of some substance in 
the blood, w r hich is comparatively innocuous to pregnant but is poisonous 
to non-pregnant animals. They, however, reached no conclusion con¬ 
cerning its nature or origin. 

8. Mende, Tyler-Smith, Lowenhardt, Beard, and others believe that 
there is an increased tendency toward uterine contractions at the periods 
at which the menstrual flow should appear if the patient were not 
pregnant, and that these reach their acme at about the date of the tenth 
menstrual period and give rise to labor. Observations of this character 
point toward the possibility of an ovarian hormone being the efficient 
cause. 

9. Yon der Ileide considers that the cause of labor should be sought 
in an anaphylactic reaction. He claims that in a certain proportion of 
cases labor will follow the intravenous injection of a few cubic centi¬ 
meters of foetal serum. In normal pregnancy he holds that foetal sub¬ 
stances are constantly gaining access to the maternal circulation, and 


CAUSE OF THE ONSET OF LABOR 


251 


give rise to the formation of definite antibodies. As term approaches, 
he believes that excessive quantities of the foetal antigen enter the 
mother’s blood, and that in the reaction which ensues between it and 
the existing antibodies, substances are set free which give rise to labor. 
Rogny in 1912 confirmed Heide’s observations upon a number of pa¬ 
tients. 

In view of the collapse of the anaphylactic theory in connection with 
the production of eclampsia, and the fact that no further contributions 
have been made to the subject, it should be held sub judice. 

10. Geyl and others are inclined to attribute the onset of labor at the 
usual time to the fact that Nature, after ages of experiment, has found 
the end of the tenth month to be the most suitable time. For when 
labor occurs at a much later period it is usually very difficult and results 
in dead children, while at an earlier period puny children are born which 
usually perish soon after birth. 

11. Eden and I have pointed out that the frequent occurrence of 
infarct formation in the placenta at term must be regarded as evidence 
of its senility, and as analogous to the atrophy of the chorion laeve at 
an earlier period. Where these changes are marked the nutrition of the 
foetus must be interfered with, and it is possible that certain of its 
metabolic products may result in stimulation of the uterine centers. At 
most this explanation is of only limited application and cannot be in¬ 
voked for the great majority of cases in which infarct formation is 
only slightly developed. 

12. It is also a well-known fact that excessive physical exercise, sud¬ 
den jars or violence, as well as extreme mental emotion, such as grief 
and anger, may lead to the termination of pregnancy. 

While, then, there is no lack of theories upon the subject, it is mani¬ 
fest that most of them are extremely unsatisfactory, and, with the ex¬ 
ception of the recent “biological” ones, none is of universal applica¬ 
tion. It is probable, therefore, that in the majority of cases a com¬ 
bination of a number of the above-mentioned causes are concerned in the 
causation of labor, and that only some slight additional stimulus is 
needed to set it in progress. On the other hand, it is possible that some 
law may be discovered in the future which will explain the rhythm of the 
various sexual functions in women—menstruation, as well as the onset of 

labor. 

Observations made in my clinic show that marked changes in metab¬ 
olism occur immediately before and at the time of labor, which in all 
probability stand in some causal relation to it. Thus, Slemons has 
shown that twenty-four hours or less before the onset of labor the output 
of nitrogen through the urine becomes considerably diminished, while 
at the same time a marked diuresis occurs, thus completely reversing the 
conditions which existed throughout the last months of pregnancy. Ac¬ 
cordingly, if the urinary analyses were made at sufficiently frequent 
intervals, it might be possible to predict the approaching onset of labor 

before the appearance of clinical symptoms. 

In order to determine the relation which these changes bear to the 
causation of labor, Slemons, at my suggestion, studied the metabolism 






252 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR 


of two pregnant women in whom labor was induced by the introduction 
of a bougie, and found that the changes were absent, or at least less 
pronounced than when labor occurred spontaneously. 

We are not prepared to draw positive conclusions from these ob¬ 
servations, but, nevertheless, they seem to indicate that at least two 
factors may he concerned in the production of labor. One occurs in 
spontaneous labor, and is associated with the process which gives rise 
to the alteration in metabolism; while the second is a purely mechanical 
irritation, which is not accompanied by such changes. What the first 
factor is cannot be determined as yet, but it seems difficult to escape the 
inference that it is some substance which gains access to the circulation 
and profoundly alters the entire metabolism, and at the same time di¬ 
rectly or indirectly stimulates the uterus to contraction. Observations 
by Zangemeister, and Momm point to similar conclusions. They found 
if women are weighed daily during the last few months of pregnancy 
that they gain 55 or 60 grams each day until three or four days before 
the onset of labor, when they suddenly lose about 1,000 grams—or as 
much as they had gained during the preceding two or three weeks. This 
phenomenon occurs so constantly as to enable them to predict the onset 
of labor several days in advance. 

Moreover, observations which I have made upon the respiratory ex¬ 
change show that at the time of labor the output of carbon dioxid is 
less than one would expect in view of the increased muscular exertion 
incident to labor. Accordingly, as the latter must necessarily be accom¬ 
panied by an increased production of carbon dioxid, it must follow that 
that resulting from the general bodily activity is diminished, so that it 
may be assumed that labor is accompanied by profound changes which 
depress the general oxidative processes far below the usual limit. 

Nearly all of the theories to which reference has been made require 
the intervention of the central nervous system for the ultimate production 
of labor, and it is generally stated that there exists in the medulla a cen- j 
ter for uterine contractions, which can be stimulated by anemia and the 
presence of various toxic substances. 

Dahl, however, denies the existence of such a center either in the brain 
or medulla, and states that if any exists, it must be situated in the lumbar 
column. Furthermore, his careful work apparently shows that no 
ganglionic cells are present in the uterus, but occur in large numbers 
in Frankenhauser’s plexus. In any event, the presence of a “uterine” 
center is not essential to the onset and completion of normal labor, as 
Franz, Kurdinowsky, and Kehrer have clearly shown that the intrinsic 
nerve supply of the uterus may suffice for its usual activities. Kurdi¬ 
nowsky has observed the completion of labor in isolated uteri, which were 
kept alive by the circulation of Locke’s fluid through their vessels; while 
Kehrer has shown that excised portions of the uterus of animals and 
women may live for hours in oxygenated Ringer’s fluid, and that their 
contractions may be graphically recorded by suitable appliances. In my 
clinic, Sun has made similar observations, and has shown that strips of 
muscle excised from the human uterus at any period of pregnancy and 
suspended in warm, oxygenated, Locke’s fluid, will continue to contract 











LABOR PAINS 


253 


rhythmically for hours. Such phenomena apparently correspond to the 
Braxton Hicks contractions of pregnancy, rather than to typical labor 
pains, but in any event they must be regarded as an essential function 
of the uterine muscle, and altogether independent of nervous control. 

As early as 1880, Rein showed that the transmission of impulses 
through the cord is not essential to the act of labor, while the more ex¬ 
tensive experiments of Kruieger and Offergeld prove that in animals 
section of the cord, and the separation of the uterus from all extrinsic 
nerve connections, has no further effect upon labor than to render it 
painless. Moreover, their observations, as well as those of Routh, Elkin 
and others, upon the course of labor in women who have sustained de¬ 
structive injuries of the lower part of the spinal cord show that labor 
may progress painlessly and normally, except that expulsive efforts on 
the part of the abdominal wall are lacking. 

Although Keiffer and others have shown that the uterus has a three¬ 
fold nervous supply, derived principally from the sympathetic system, 
partly from branches of the lumbar cord, and partly from its intrinsic 
nerves, and that contractions may follow the stimulation of any of them, 
the evidence at our disposal justifies the following conclusions: That 
the intrinsic nerves are the main factor concerned in the production 
of uterine contractions; that the central nervous system has principally 
a regulative function, makes possible the perception of pain, and con¬ 
trols the voluntary abdominal contractions; and that the sympathetic 
system regulates the vascular conditions. 

Labor Pains.—With the onset of labor, the painless intermittent con¬ 
tractions which have persisted throughout pregnancy are replaced by 
others of increasing intensity, giving rise to severe pain, and bringing 
about the dilatation of the cervix and the expulsion of the child and pla¬ 
centa. 

The uterine contractions, just as those of all other non-striated mus¬ 
cles, are independent of the will of the patient, and can neither be in¬ 
creased nor diminished in frequency by her volition. But at the same 
time they may be affected by the emotions, and any sudden excitement 
may either check them or cause them to become more violent. Thus, it is 
a matter of common observation that the entrance of the obstetrician 
may be followed by a temporary lull in the intensity and frequency of 

the pains. 

The contractions begin slowly, gradually reach an acme, and then 
gradually diminish in intensity, the active process being followed by a 
pause of some length. The tracings of Schatz and Polaillon show that 
the period of increase occupies the greater poition of the pain, and that 
its acme is of very short duration. In the lower animals which possess 
bicornuate uteri the contractions are distinctly peristaltic in character; 
and Schatz believes that such is also the case in human beings. It is im¬ 
portant to bear in mind that labor pains are effective only during the 
period of increase, and that the tightly contracted organ is worthless 
from a mechanical standpoint. 

These uterine contractions are nearly always accompanied by painful 
sensations, whence the term “labor pains,” although the amount of suf- 








254 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR 


fering varies greatly in different individuals. The pain usually begins 
in the sacral region and then slowly passes to the abdomen and down the 
thighs. In the early stages of labor it is probably due to pressure upon 
the nerve-endings between the muscle fibers; but in the later stages it is 
augmented by the overstretching and dilatation of the soft parts, and 
becomes most marked when the head distends the vulva just before its 
birth. Usually the final pains are very severe, and may be almost in¬ 
supportable, but occasionally the suffering is very slight, and, in rare 
instances, labor may be almost entirely painless, even though the patient 
be perfectly conscious. A number of such cases have been collected by 
Ooliez and Wolff. 

At the onset of labor the pains come on at intervals *of from fifteen 
to thirty minutes; as it advances they gradually become more frequent, 
and eventually occur every two or three minutes. Their average duration 
is about one minute—thirty to ninety seconds—though suffering is not 
experienced during the entire contraction, as the hand placed over the 
abdomen may feel the uterus becoming hard for several seconds before 
the patient perceives the slightest pain. 

Force Exerted by Labor Pains.—On this point there has been a good 
deal of misconception, and a tendency toward exaggeration appears in 
the writings of not a few authors. Thus Sterne, in Tristram Shandy, 
estimated that the force exerted at each pain during labor amounted 
to 470 pounds, while Professor Haughton put it at 577 pounds. Poppel, 
Duncan, Ribemont, and others have attempted to approximate it by de¬ 
termining the force necessary to cause the rupture of the membranes 
outside of the body. This, they found, varied markedly, and in 100 ex¬ 
periments Duncan placed the extremes at 4 and 37.58 pounds respec¬ 
tively, with an average of 16.73 pounds. 

Joulin and other observers have attempted to solve the problem by 
calculating the force exerted in forceps deliveries. Thus, on interpolat¬ 
ing a dynamometer between the operator and the handles of the instru¬ 
ment, it was found that the tractile force rarely exceeded 80, though in 
some cases it reached 100 pounds. A greater direct force than this can¬ 
not come into play, as it has been shown that one of 120 pounds is suffi¬ 
cient to tear the child’s head from its body. 

Schatz studied the subject by inserting into the uterus a rubber bag 
which was connected with a manometer. In this way he found that the 
intra-uterine pressure, in the intervals between the contractions, was 
represented by a column of mercury 20 millimeters high, 5 of which werd 
due to the tonicity of the uterine walls and 15 to its contents. During 
the pains, however, the mercury rose to a height of from 80 to 250 milli¬ 
meters, which corresponds to a force of 8V2 to 2 7 Vo pounds. He also 
showed that the force exerted by the uterus increases markedly when the 
foetus is partially expelled from it. 

A rough idea may also be gained by estimating the expenditure of 
energy necessary to restrain the head as it emerges from the vulva. This 
rarely exceeds 50 pounds, although the obstetrician frequently finds 
it impossible to hold it back at the acme of a pain. This inability is in 
great part due to the disadvantageous manner in which one’s energy 












PHYSICAL CHANGES DURING UTERINE CONTRACTIONS 255 

u 

is exerted, rather than to the actual force exerted by the uterine and 
abdominal contractions. 

Physical Changes during Uterine Contractions. —During contraction 
the uterus undergoes definite changes in shape. With the patient on her 
back, the organ in the flaccid state rests upon the vertebral column, and 
its transverse equals or exceeds its vertical diameter. But when it con¬ 
tracts the uterus leaves the vertebral column, becomes more erect, 
pushes the anterior abdominal wall forward, and its long axis comes into 
approximation with that of the superior strait. At the same time the 
vertical increases at the expense of the transverse diameter (Fig. 210). 

The dilatation of the cervix is usually brought about solely by the 
action of the uterine muscle, whereas during the expulsion of the child 
the muscles of the abdominal wall also come into play. During the sec¬ 
ond stage the patient braces her body against some fixed object, takes a 
deep inspiration, closes the glottis, and makes forcible straining move- 



Fig. 210. —Composite Picture, showing Shape of Abdomen before and during a 
Uterine Contraction, the Darker Outlines indicating Contraction. 


ments with the abdominal and respiratory muscles. By these means the 
intra-abdominal pressure is markedly increased, and is transmitted di¬ 
rectly to the uterus. At first these movements are voluntary, but as 
labor advances they pass beyond the control of the will, and may occur 
even with the patient under profound anesthesia. 

The abdominal muscles, therefore, play an important part in the ex¬ 
pulsion of the child, which in many instances makes no progress without 
their aid. The fact that spontaneous labors occasionally occur in women 
who are paralyzed from the waist down shows that their action is not 
indispensable in every case; but, on the other hand, the application of 
low forceps is frequently necessitated by the inability of the abdominal 
muscles to do their work, or to the unwillingness of the patient to 
bear the pain associated with their employment. 

The various ligamentary structures connected with the uterus also 
take part in the contractions. Of these the most important are the round 
ligaments, which in contracting tend to draw the fundus of the uterus 





















256 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR 


forward and to fix it in position. They can be readily palpated through 
the abdominal wall., and some idea of the intensity of the uterine con¬ 
tractions may be gained from their consistency. 

The part played by the vagina during labor is almost entirely passive, 
and it is only after the expulsion of the child that the contraction of the 
muscular elements in its walls comes into play. 

The general arterial tension is raised during the labor pains, as is in¬ 
dicated by the Hushed look of the patient, as well as by the more accu¬ 
rate observations of Yaquez, and of Slemons and Goldsborough in my 
clinic. The pulse becomes accelerated during, and slower in the intervals 
between, the pains. It is also stated that the temperature rises a fraction 
of a degree during each pain, though its detection requires the employ¬ 
ment of very accurate thermometers. Respiration becomes slower during 
the contractions, more rapid in the interval between them, and is totally 
abolished during the expulsive pains of the second stage of labor. My 
observations upon the respiratory exchange show that the consumption 
of oxygen and the output of carbon dioxid are increased during labor, 
but not to the extent one would suppose. As has already been stated, 
this probably indicates that the general oxidative processes of the body 
are reduced to a minimum at this time, and consequently that the actual 
work of labor is accomplished with comparatively less expenditure of 
energy than in the case of an equal amount of muscular exertion at 
other times. 

Clinical Course of Labor. —Before taking up the consideration of the 
forces concerned in the expulsion of the foetus and the mechanism by ' 
which it is accomplished, it is advisable for the student to follow as a 
spectator the course of parturition in a primiparous woman. 

Several weeks before the onset of labor the abdomen undergoes a 
marked change in shape, its lower portion becoming more pendulous, 
whereas in the neighborhood of the costal margin it looks decidedly flat¬ 
ter. This change is perceived by the woman herself, who feels that her j 
waist has become lower; and occasionally it occurs so suddenly as to cause 
her to fear that something has given way inside the abdomen. Abdomi¬ 
nal palpation shows that the change is due to the fact that the fundus of 
the uterus has descended from the position which it occupied at the 
ninth month, and resumed that of the eighth, and that the head, which 
was previously freely movable, has become fixed in the superior strait. 
These changes are most pronounced in primiparae, and frequently do 
not occur in multiparae until the onset of labor. 

After this the patient experiences considerable relief from the respira¬ 
tory disturbances from which she may have suffered; but at the same 
time locomotion may become more difficult, and she may suffer from 
severe cramplike pains in the lower extremities and a more frequent 
desire to urinate. 

During the last few weeks of pregnancy the vaginal secretion is in¬ 
creased in amount, the labia become more swollen and succulent, and in 
multiparae gape more or less widely, while the patient may experience 
a few transient pains for a number of days before confinement the so- 
called “dolores praesagientes.” 







LITERATURE 


265 , 


yer-Ruegg. Eihautberstung olme Unterbrechung der Schwangerschaft Zeit- 
sehr. f. Geb. u. Gyn., 1904, li, 419-468. 

•mm. Ein neues Zeichen fur den nachen bevorstehenden Geburtseintritt. Zen- 
tralbl. f. Gyn., 1920, 233-238. 
egele. Yersuch eines Systems der Geburtsliiilfe, 1812, 97. 

LAILLON. Recherches sur la physiologie de 1 ’uterus gravide. Paris, 1880. 
ppel. Ueber die Resistenz der Eihaute. Monatsschr. f. Geburtsk., 1863, xxii, 
1-15. 

in. Beitrag zur Lehre von de,r Innervation des Uterus. Pfluger’s Archiv, 1880, 
xxiii, 68. 

gny. The Use of Foetal Serum to Cause the Onset of Labor. Am. Jour, of 
Obst., 1912, lxvi, 1-22. 

UTH. Parturit'on during Paraplegia. Trans. London Obst. Soc., 1897, xxix, 
191-200. 

uerbruck u. Heyde. Untersuchungen liber die Ursachen des Geburtseintrittes. 

Miinchener med. Wochenschr., 1910, 2617-2619. 
anzoni. U.rsache der Geburt. Lehrbuch der Geburtshiilfe, II. Aufl., 1853, 
165-167. 

hatz. Beitrage zur phvsiologischen Geburtskunde. Archiv f. Gyn., 1872, iii, 
58-144. 

Ueber die Formen der Wehencurve und iiber die Peristaltik des menschlichen 
Uterus. Archiv f. Gyn., 1886, xxvii, 284-292. 

Ueber die Entwickelung der Kraft des Uterus im Yerlaufe der Geburt. Verh. 

d. deutschen Gesell. fiir Gyn., 1895, vi, 531-542. 

,emons. Metabolism during Pregnancy, Labor and the Puerperium. Johns 
Hopkins Hospital Reports, 1904, xii, 111-144. 
i'LEr-Smith. The Principles and Practice of Obstetrics. London, 1849. 

\quez. De la tension arterielle pendant la grossesse. Bull, de la d’obst. de 
Paris, 1906, ix, 30-33. 

arnier. Combien de temps dure l’accouchement. L’obstetrique journaliere, 
1900, 174-181. 

illiams. The Frequency and Significance of Infarcts of the Placenta. Amer. 
Jour, of Obst., 1900, xli, No. 6. 

OLFF. Ueber schmerzlose Geburtswehen. Archiv f. Gyn., 1906, lxxvii, 402-418. 
\ngemeister. Ueber das Korpergewicht Schwangerer. Zeitschr. f. Geb. u. Gyn., 
1916, lxxviii, 325-365. 






CHAPTEE XI 


THE FORCES CONCERNED IN LABOR 

The Cervix in the Later Part of Pregnancy.—On vaginal examinatic 

in the later months of pregnancy, the cervix is found to be much_soft< 
and somewhat broader than in the non-pregnant condition. At the san 
time it usually gives the impression of being considerably shortened, esp 
daily in its anterior portion. This condition led Mauriceau, Koedere 
and nearly all of the earlier authorities to believe that from the fift 
month onward the upper portion of the cervix gradually became oblite 
ated and contributed to the enlargement of the uterine cavity, that whic 
was left at the end of pregnancy representing merely its inferior end. 

Stoltz, in 1826, stated that tl 
shortening was only apparent, beir 
brought about by a fusiform dilat; 
tion of the cervical canal which r< 
suited in the approach of the intern; 
to the, external os. He believed th; 
the [ceyvix retained its integrity unt 
about two weeks before the onset ( 
labor, when the canal slowly becan 
obliterated and canie to form part ( 
the uterine cavityTj Matthews Dunca 
accepted these views, but pointed 01 
that they had been anticipated by the anatomical work of Yerhegei 
De Graaf, and Weitbrecht (1710-1750). At the same time he insiste 
upon certain modifications, holding that the cervical canal remaine 
practically unchanged until the onset of labor. His statement soo 
received abundant confirmation from the observations of Holt, Miille 
Lott, Taylor, Lusk, and many subsequent investigators. 

Muller pointed out that the apparent shortening of the cervix w£ 
due to the marked anteflexion of the uterus and the depression of tl 
anterior fornix of the vagina by the presenting payt, to which shoul 
be added the increased succulence of the entire genital tract. He ah 
stated that the finger, at the end of pregnancy, could be introduced inf 
the canal for a distance of 2.5 to 3 centimeters before it was arrested b 
the internal os. His conclusions were verified by further clinical ol 
servation, so that it is now generally admitted that in the great majorit 
of cases the canal remains practically unaltered until the onset of labo: 
and that it may even be slightly longer than in the non-pregnant cond 
tion, thus indicating that the cervix shares somewhat in the genera 
hypertrophy of the uterus. 



266 






LOWER UTERINE SEGMENT 


207 



In recent years the results obtained 
received additional confirmation 
through the bodies of women 
dying late in pregnancy. Valu¬ 
able contributions along these 
lines have been made by Wal- 
deyer, Schroeder, Braune and 
Zweifel, Pinard and Varnier, 

Leopold, and others. 

Lower Uterine Segment.— 

For a short time after the ap¬ 
pearance of Miiller’s work in 
18(!8, the question concerning 
the behavior of the cervix was 
regarded as practically settled; 
but these hopes were shattered 
in 1872 by the studies of 
Braune upon frozen sections riG 
made through a woman who 


during life have 
sections made 


218. —Cervix at the End of Pregnancy 
(Waldeyer). X Y- 


by examination 
from the study of frozen 




had died 


during 


stage 


Fig. 


219. —Cervix at the End of Pregnancy 
(Braune and Zweifel). X Y . 


the second 
of labor. His specimen 
showed distinctly that the in¬ 
terior of the uterus was divided 
into two parts by a projecting 
circular ridge, 10 to ll^centi 
meters above the margins m 
the dilated external os, its 
situation being marked by a 
large vein, and by the define- 

o s %J 

tion of the peritoneum from 
the anterior surface of the 
uterus (Fig. 221). The por¬ 
tion above it possessed thick 
walls, while the remainder ap- 
peared as a thin-walled, mus¬ 
cular tube through which the 
head had partially passed. 

Braune identified this ring or 
ridge with the internal os, and 
concluded that everything lie- 
low it had been derived from 
the cervix; nor did he think it 
remarkable that the small canal 
which had existed up to the 
time of labor should have been 
converted into a structure of 
such dimensions. 

Bandl, in his work upon rupture of the uterus, which appeared in 
1875, pointed out that when such an accident occurs the point of rupture 


Fig. 220. —Cervix at the End of Pregnancy, 
showing Preservation of Canal (Leopold). 

X l A- 








270 


THE FORCES CONCERNED IN LABOR 


the first months of pregnancy. It is therefore apparent that those who 
designate the upper opening of the isthmus as the inteinal os must 
claim that the lower uterine segment is derived from the ceivix, while 
those who place the internal os at the junction between the isthmus and 
cervical canal are justified in holding that the passive portion of the 
uterus is derived both from its body and cervix. To obviate ibis difficulty, 
Aschoff proposes to designate the upper and lov'er openings of the 
isthmus, respectively, as the anatomical and histological internal os. 
If the contraction ring corresponds to the former, the lower uterine 



Fig. 223.—My Frozen Section, showing Condition of the Birth Canal in First 

Part of Second Stage of Labor. X 

C.R., contracting ring; o.e., external os. 

segment must be derived from the tissue lying between it and the his¬ 
tological internal os. 

In a symposium upon the subject before the Leipzig Obstetrical So¬ 
ciety in 1914, Veit, and Zweifel, while in general agreeing with Aschoff, 
held that the introduction of the term isthmus had tended rather to 
complicate than to clarify the question. They therefore proposed that, 
as the isthmus of the non-pregnant uterus becomes the lower uterine 
segment of the parturient organ, it should be given a single appellation 
at all times, and that the narrow passage interpolated between the uterine 
cavity and the cervical canal of the non-pregnant woman should also be 
designated as the lower uterine segment. 

Plate IX represents a vertical mesial through the uterus of a 
woman, seven months pregnant, who died at the Johns Hopkins Hospital 










PLATE IX 



SEVEN AND A HALF MONTHS’ PREGNANT UTERUS FROM WOMAN DYING 

IN THE FIRST STAGE OF LABOR. X K- 






CHANGES IN THE UTERUS DURING THE FIRST STAGE OF LABOR 271 


I 


during premature labor. In this it is clearly seen that the external os is 
not dilated, but that the cervical canal has become obliterated and a dis¬ 
tinct lower uterine segment has been formed. Careful examination 
shows that the latter is lined with a typical cervical 
mucous membrane for a distance of 3.5 to 4 centi¬ 
meters from the margins of the external os, whereas 
above this point its lining is composed of decidua. 

Fig. 223 represents part of a frozen section 
through a pregnant cadaver, shown in Plate I, which 
was kindly placed at my disposal by Drs. J. Holmes 
Smith and E. E. Neale. The woman, who had a gen¬ 
erally contracted rachitic pelvis, died undelivered, 
with the child presenting by the breech and with the 
membranes protruding from the vulva. The cervical 
canal was obliterated and the external os fully di¬ 
lated, its margins being 1 millimeter thick. There 
was no trace of the internal os. Seven centimeters 
above the external os was a well-marked contraction 
ring. Unfortunately, the specimen was so macerated 
that the lining membrane of the cervical canal and 
lower uterine segment had disappeared. Micro¬ 
scopical examination revealed only a few cervical 
glands in the neighborhood of the external os. 

Hofmeier, in 1886, demonstrated that the struc¬ 
ture of the lower uterine segment is not homogeneous, 
and that the portion which corresponds to the cervix 
is composed of dense connective tissue rich in elastic 
fibers, while its upper part is made up of muscular 
lamellae which pursue an almost parallel course, 
whereas as soon as the contraction ring is reached 
the uterine musculature takes on its characteristic ap¬ 
pearance. 

Changes in the Uterus during the First Stage of 

Labor.—Passing from these more or less theoretical 
considerations to the condition of the uterus at the 
end of pregnancy, we find that the organ is made up 
of two parts; a large, thin-walled, muscular sac—the 
body—to the lower end of which the small cervix is 
attached. The wall of the former, including the de¬ 
cidua and foetal membranes, rarely exceeds 7 milli¬ 
meters in thickness. The cervix is softened and 
succulent. It usually presents a fusiform canal, 3 to 4 centimeters long, 
which is bounded at its upper and lower ends by the internal and ex¬ 
ternal os respectively; its walls rarely exceeding 1.5 centimeters in 
thickness. Occasionally, however, the resistance of the internal os has 
yielded, so that the upper part of the cervical canal has become con¬ 
tinuous with the uterine cavity. The condition of the external os varies 
in primiparous or multiparous women. In the former it barely admits 
the tip of the finger; while in the latter it is widely gaping, so that the 


o.e. 


Fig. 224. —Section 

through Lower 
Uterine Segment 
and Cervix, show¬ 
ing Rhomboidal 
Arrangement of 
Muscle Fibers in 
Former and Dense 
Structure in 
Latter (Hofmeier). 

P., peritoneal cover¬ 
ing of uterus; o.e., 
os externum; o.i., 
os internum. 















THE FORCES CONCERNED IN LABOR 


272 

index finger can be readily passed through the funnel-shaped cervical 
canal up to the internal os. 

During labor, under the influence of the uterine contractions, the 
uterus becomes differentiated into two distinct portions, which are sepa¬ 
rated from one another by the contraction ring. The upper is the active 
contractile portion and becomes thicker as labor advances, while the 



Fig. 225. Fig. 226. 

Figs. 225, 226. —Diagrams of Birth Canal at End of Pregnancy and During 
Second Stage of Labor, Showing Formation of Birth Canal (Schroeder). 



lower, together with the cervical canal, plays a passive part, becoming 
converted into a thin-walled muscular tube for the transmission of the 
foetus (Fig. 226). On abdominal palpation, even before the rupture of 
the membranes, two zones can sometimes be differentiated during a con¬ 
traction, the upper 
one of which is firm 
and hard, while the 
lower affords a semi- 
fluctuant sensation. 
The former repre¬ 
sents the contractile 
portion of the uterus, 
the latter the dis¬ 
tended passive por¬ 
tion. 

AVith the onset of 
labor pains the fluid 
contents of the uterus 
are subjected to pres¬ 
sure, and the force 

Fig. 227.— Dilatation of Cervix, Funnel-shaped Oblit- i i n 

eration of Internal Os and Cervical Canal (Leo- ' h 

pold). liquor amnii is trans¬ 

mitted equally in all 

directions. As the lower uterine segment and the cervix will naturally 
constitute a point of least resistance, they are consequently subjected 
to an increased tension and distention. 

Again, since the cervix is perforated by its canal, the fluid pressure 





















CHANGES IN THE UTERUS DURING THE FIRST STAGE OF LABOR 273 

exerted by the bag of waters tends to cause its obliteration and final dila¬ 
tation, which is aided by the traction exerted upon its margins by the 
contracting fibers of the upper portion of the body of the uterus. When 
complete dilatation has been effected, the external os is about 10 centi¬ 
meters in diameter, and its margins lie 8 to 10 centimeters below the 



Fig. 228. —Dilatation of Cervix further advanced than in Fig. 227 (Leopold). X 1. 


contraction ring, while all trace of the internal os has disappeared. At 
the same time the bladder is gradually drawn up in front of the lower 
uterine segment until it becomes almost entirely an abdominal organ. 

The dilatation of the cervix should be regarded as consisting of two 
stages: first, obliteration of the canal; and, second, dilatation of the ex- 



Fig. 229. —Cervical Canal completely Obliterated, External Os Intact. X 1 


ternal os. The obliteration occurs from above downward, the beginning 
being indicated by a funnel-shaped depression at the region of the in¬ 
ternal os, which gradually increases in extent and depth until the entire 
canal has disappeared, when the uterine cavity is separated from the 
vagina merely by the external os. This is clearly shown in Figs. 227, 228, 






274 


THE FORCES CONCERNED IN LABOR 



and 229, as well as in Figs. 230, 231, and 232, which represent recon¬ 
structions from the frozen sections of Schroeder, Winter and Saxinger. 

After the cervical canal has become obliterated, dilatation of the 
external os occurs. In many instances its margin becomes extremely 
thin, and when tense gives a sensation as if it might cut the examining 

finger. These changes 
are brought about almost 
entirely by the force ex¬ 
erted by the bag of 
waters, or, when that has 
ruptured prematurely, by 
the pressure exerted by 
the presenting part itself. 

The course of events 
differs considerably ac¬ 
cording as the woman is 
in her first or a subse¬ 
quent pregnancy. In the 
former case marked re¬ 
sistance is offered by the 
external os, and a consid¬ 
erable time must elapse 
before complete dilatation is accomplished; whereas in the latter, the os 
is gaping and very little force is required for its complete dilatation 
after the cervical canal has become obliterated. 


Fig. 230. —Dilatation of Cervix, Funnel-shaped 
Obliteration of Internal Os; Canal 2 Centi¬ 
meters Long (Schroeder). X 3 / 2- 




Fig. 231.—Dilatation of Cervix, all but 
Lower 10 Millimeters of Canal ob¬ 
literated; External Os Unchanged 
(Winter). X Yz- 


Fig. 232. —Dilatation of Cervix, all 
but Lower 3 Millimeters of Canal 
obliterated; External Os Unchanged 
(Saninger). X Yz- 


Changes in the Uterus during the Second Stage of Labor. —By the 

end of the first stage of labor the uterine contractions have resulted 
in the differentiation of the organ into two parts, which are separated 
from one another by the contraction ring. Above is the active, con- 






CHANGES IN THE UTERUS DURING THE SECOND STAGE OF LABOR 275 

tractile portion, which becomes thicker as labor advances, and below 
the thin-walled, passive, lower uterine segment and cervix (Fig. 226). 

While these changes are being effected, there has been no descent on 
the part of the foetus, and, as a rule, the position of the presenting part 
remains unchanged until after the cervix has become completely dilated. 
\\ ith the commencement of the second stage, however, descent begins, 
and under normal conditions continues slowly but steadily until delivery 
is accomplished. Naturally, the differentiation into stages is more or 
less arbitrary, so that it occasionally happens that the presenting part 
begins to descend during the latter part of the first stage. 

After it has brought about complete dila¬ 
tation of the cervix, the bag of waters has 
served its function, and rupture usually now 
occurs, which is manifested by a sudden rush 
of a variable quantity of a tolerably clear 
fluid from the vagina. On the other hand, 
the membranes may give way some time be¬ 
fore complete dilatation of the cervix has 
been brought about; while occasionally they 
may retain their integrity until the completion 
of labor, so that the foetus is born surrounded 
by them, the portion covering its head being 
designated as a caul. 

Attention has already been directed to 
the changes in shape which the uterus pre¬ 
sents during contraction. These may be 
noticed in the first, but more especially in 
the second, stage, when the organ increases 
considerably in length, and at the same 
time diminishes in its transverse and antero¬ 
posterior diameters with each contraction. 

The increase in length is due partly to the 

stretching of the lower uterine segment, and partly to a straighten¬ 
ing out of the foetus; but we are unable to make definite state¬ 
ments as to its extent, for at present we possess no means of ascer¬ 
taining how far the retraction of the upper portion of the uterus 
may serve to counterbalance the stretching of its lower segment. With 
the formation of the lower uterine segment, the upper portion of the 
uterus increases greatly in thickness, and, as labor proceeds, covers a 
progressively decreasing portion of the child. Thus, when the head is 
upon the perineum less than one-half of the foetus is in the upper seg¬ 
ment. In obstructed labors, in which definite disproportion exists be¬ 
tween the size of the presenting part and the peivic canal, the lower 
uterine segment is subjected to excessive stretching, and consequently 
the contraction ring assumes a much higher level, when it can be 
palpated as a distinct transverse or oblique ridge a short distance below 
the umbilicus. In such circumstances, its recognition indicates that 
rupture of the uterus is imminent and will occur if the labor is not 
promptly ended. 



Fig. 233. —Diagram show¬ 
ing Action of Intra¬ 
uterine Pressure, Mem¬ 
branes not Ruptured. 








276 


THE FORCES CONCERNED IN LABOR 




Forces Concerned in Labor.—As long as the membranes are unrup¬ 
tured during the first stage and the uterus contains a normal quantity 

of amniotic fluid, as well as in the rare in¬ 
stances in which they remain intact, dur¬ 
ing the second stage, whatever force is 
exerted by the contracting uterus is trans¬ 
mitted to the liquor amnii, and by it to the 
foetus. In accordance with the laws of 
fluid pressure, therefore, it is applied with 
equal intensity to all portions of the child, 
and, were it not that the lower uterine seg¬ 
ment and cervix represent the point of least 
resistance in the uterus, all its effect would 
be wasted; whereas, in the circumstances, 
it gives rise to the formation of the lower 
uterine segment and the dilatation of the 
cervix, but plays no part in causing the 
descent of the child. Attention was first 
directed to this point by Schatz and Lahs, 
and all subsequent authorities have accepted 
their conclusions. 

After rupture of the membranes, a 
greater or lesser portion of the amniotic 
fluid escapes from the uterus, but in vertex 
presentations the presenting part usually acts as a fairly efficient tampon 
and causes the retention of a quantity suffi¬ 
cient to fill out the interstices between the 
foetus and the uterine walls. Lahs believed 
the amount retained was usually sufficient to 
prevent actual contact with the surface of 
the foetus, and therefore held that extrusion 
of the latter was brought about by fluid pres¬ 
sure alone. He argued that in such cir¬ 
cumstances (Fig. 234) the entire surface of 
the foetus, except the portion projecting 
through the cervix, would be subjected to 
fluid pressure, which, as it is equal in all 
directions, would exert no effect upon the 
foetus, except in a line passing through the 
center of the portion not subjected to it, thus 
manifesting itself as a downward force bring¬ 
ing about descent. 

On the other hand, Lahs held that in all 
other presentations, as well as in vertex 
presentations after the amniotic fluid has al¬ 
most completely drained off, other factors 
come into play which he regarded as dis¬ 
tinctly pathological. In such cases the contracting uterus would come in 
direct contact with the surface of the foetus, and the force exerted by the 


Fig. 235.—Diagram showing 
Direct Pressure Exerted 
by Fundus after Complete 
Evacuation of Amniotic 
Fluid. 


Fig. 234.—Diagram showing 
Action of Intra-uterine 
Pressure after Rupture of 
the Membranes. 







FORCES CONCERNED IN LABOR 


277 


fundus would be directly transmitted to the presenting part by way of 
the vertebral column. 

Most recent writers have not hesitated to accept Lahs’s interpretation, 
but Olshausen in 1901 directed attentions to the fact that the latter force 
comes into play even in normal vertex presentations. The former pointed 
out that only four frozen sections, through women dying in the second 
stage of labor, were available for the study of the question—namely, 
two of Braune and those of Chiari and of Barbour—and that in three of 
them the fundus was in direct contact with the breech of the child. 
A\ arnekros made similar observations upon the living woman by means 
of the X-ray. Furthermore, Olshausen estimated that at least 300 cubic 
centimeters of amniotic fluid were required to fill out the interstices 
between the surface of the foetus and the uterine wall, and stated that 
fluid pressure could play no part in the expulsion of the foetus unless a 
| greater quantity were present. 

Upon measuring the amount of amniotic fluid escaping when the 
child was born, which practically represents the quantity remaining in 
the uterus after rupture of the membranes, he found that in 80 per 
cent, of the primiparae it did not exceed 300 cubic centimeters; while 
in 60 per cent, it was not over 200 cubic centimeters—an amount by no 
means sufficient to fill out the interstices, let alone to separate the breech 
from the fundus, which is essential for the proper action of fluid pres¬ 
sure. He therefore concluded that in such circumstances direct pres¬ 
sure must be exerted upon the breech, whence it is transmitted through 
the vertebral column to the head, and tliat this is rendered possible by 
a straightening out of the body of the child and its conversion into a 
comparatively rigid object, which is brought about by the diminution 
in the transverse and anteroposterior diameters of the uterus. 

The descent of the presenting part is also partly due to the straighten¬ 
ing out of the body of the child. According to Schroeder, its length 
from vertex to breech is increased by 5.5 centimeters as a result of this 
extension; while Olshausen considers that the increase is considerably 
greater, and may be as much as 13 centimeters. Part of this, it is true, 
is counterbalanced by the greater length of the uterus, but the remainder 
is an important factor in causing descent. 

In addition to these factors, the contractions of the abdominal mus¬ 
cles of the woman also play no mean part in effecting the extrusion of 
the child; indeed, according to Schroeder, they alone bring it about. 
Olshausen, while not denying their importance, does not consider that 
they are the sole factors concerned. It is apparent, however, that their 
action is usually essential, for when it is entirely absent, or only partially 
comes into play, labor is frequently so delayed that resort to forceps 
becomes necessary. 

When the head has descended through the pelvis and is resting on the 
pelvic floor, more than half of the entire length of the child lies beneath 
the contraction ring; moreover, as the upper portion of the uterus be¬ 
comes thicker and thicker, it necessarily exerts a diminished effect, so 
that, in the majority of cases, it becomes essential that the abdominal 
contractions should participate in the work. 




27S 


THE FORCES CONCERNED IN LABOR 


Immediately after the birth of the child a marked change occurs in 
the position and size of the uterus, and on palpation it can be distin¬ 
guished as a firm, rounded body which does not reach to the umbilicus. 
At this time its contracted and retracted body is freely movable above 
the collapsed lower uterine segment and cervix, and can readily be dis¬ 
placed in any desired direction. 

Changes in the Vagina and Pelvic Floor during Labor.—The outlet 

of the pelvis is closed by a number of layers of tissue, which together con¬ 
stitute what is known as the pelvic floor. Beginning from within out¬ 
ward one meets successively with the peritoneum, the subperitoneal con¬ 
nective-tissue, the internal pelvic fascia, the levator ani and coccygeus 
muscles, the external pelvic and perineal fascia, and, included between 
the latter, the superficial muscles of the perineum, external to which are 
the subcutaneous tissue and the cutaneous covering of the perineal and 
vulval regions. 

Of these structures the most important are the levator ani muscle 
and the fascia covering its upper and lower surfaces, which for pratical 
purposes may be considered as constituting the pelvic floor. This muscle 
closes the lower end of the pelvic cavity as a diaphragm, and presents a 
concave upper and a convex lower surface. On either side it consists of 
a pubic and iliac portion; the former is a band 2 to 2.5 centimeters in 
width, which arises from the horizontal ramus of the pubis 3 to 4 centi¬ 
meters below its upper margin, and 1 to 1.5 centimeters from the sym¬ 
physis pubis. Its fibers pass backward and encircle the rectum, and 
possibly give off a few fibers which pass behind the vagina. The greater 
or iliac portion of the muscle arises on either side from the white line— 
the tendinous arch of the pelvic fascia—and from the ischial spine, at a 
distance of about 5 centimeters below the margin of the superior strait. 
Its fibers do not possess a uniform arrangement, but, according to the 
researches of Dickinson, the following portions can be distinguished: 
•Passing from before backward, there is a narrow band which crosses the 
pubic portion and descends to the rectovaginal septum. The greater 
part of the muscle passes backward and unites with that from the other 
side of the rectum, while the posterior portions meet together in a tendi¬ 
nous rhaphe in front of the coccyx, the most posterior fibers being at¬ 
tached to the bone itself. The posterior and lateral portions of the 
pelvic floor, which are not filled out by the levator ani muscle, are 
occupied by the pyriformis and coccygeus muscles on either side. 

The levator ani muscle varies from 3 to 5 millimeters in thickness, 
though its margins, which encircle the rectum and vagina, are somewhat 
thicker. It undergoes considerable hypertrophy during pregnancy, and 
on vaginal examination its internal margin can be felt as a thick band 
extending backward from the pubis and encircling the vagina, about 2 
centimeters above the hymen. On contraction it serves to draw both the 
rectum and vagina forward and upward in the direction of the symphysis 
pubis, and is to be regarded as the real closer of the vagina, since the 
constrictor cunni, one of the superficial muscles of the peritoneum, is 
too delicate in structure to have more than an accessory function. 

Although Farabeuf estimated that the levator ani upon contraction 









'■> re*-»■- 


Fig 237. _ The Pelvic iloor seen from Below (Kelly). 



















280 


THE FORCES CONCERNED IN LABOR 


exerted a force of from 12 to 15 kilograms, it is generally believed that it 
is not sufficiently strong to afford support to the pelvic contents were it 
not reinforced by the strong pelvic fascia. Paramore in 1910 expressed a 
contrary view, but the prevailing opinion was well summarized by 
Eduard Martin in 1911. The internal pelvic fascia, which forms the 
upper covering of the levator ani, is attached to the margin of the su¬ 
perior strait, where it is joined by the fascia lining the iliac lossae, as 
well as by the transverse fascia of the abdominal walls. It passes down 
over the pyriformis and the upper half of the obturator interims muscle, 
and is firmly attached to the periosteum covering the lateral wall of the 
pelvis, the white line indicating its point of deflection from the latter, 

whence it spreads out over the upper surface 
of the levator ani and coccygeus muscles. 

The inferior fascial covering of the pelvic 
diaphragm is divided into two parts at a line 
drawn between the ischial tuberosities. Its pos¬ 
terior portion consists of a single layer which, 
taking its origin from the sacrosciatic ligament 
and the ischial tuberosity, passes up over the 
inner surface of the ischial bones and the 
obturator internus muscles to the white line, 

in whose formation it 
takes part. From this 
tendinous structure it is 
reflected at an acute 
angle over upon the in¬ 
ferior surface of the 
levator ani, the space in¬ 
cluded between the latter 
and the lateral pelvic wall 
being designated as the 
ischiorectal fossa. The 
structure filling out the triangular space between the pubic arch and a 
line joining the ischial tuberosities is known as the urogenital diaphragm, 
which, exclusive of skin and subcutaneous fat, consists principally of 
three layers of fascia: (1) The deep perineal fascia which covers the an¬ 

terior portion of the inferior surface of the levator ani muscle and is 
continuous with the fascia just described; (2) the middle perineal fascia 
which is separated from the former by a narrow space in which are 
situated the pudic vessels and nerves; (3) the superficial perineal fascia 
which, together with the layer just described, form a compartment in 
which lie the superficial perineal muscles, with the exception of the 
sphincter ani, the rami of the clitoris, the vestibular bulbs, and the vulvo¬ 
vaginal glands. 

The superficial perineal muscles consist of the constrictor cunni, the 
ischiocavernosus, and the transversus perinei muscles. These structures 
are delicately formed and possess no obstetrical significance, except the 
last-named muscles, which are always torn through in perineal lacera¬ 
tions, when they serve in great part to bring about gaping of the wound. 



Fig 


THREE LAYERS OF 
THE PERINEAL FASCIA 


238.—Diagram showing Arrangement of Pel¬ 
vic and Perineal Fascia (Tarnier). 



CHANGES IN THE VAGINA AND PELVIC FLOOR DURING LABOR 281 




Fig. 240. —Frozen Section showing Condition of Birth Canal in Last Month of 

Pregnancy (Braune and Zweifel). X 3^- 


Studdiford holds that the perineal body, anterior and interior to the 
sphincter ani, contains numerous strands of non-striated muscle, which 
also play an important part in perineal tears. 


Constrictor cunni 
M. Ischio-cavernosus 


M. transversus perinei 


Centrum tendineum 


Levator ani 


Sphincter ani 


Fig. 239. —Pelvic Floor distended by Presenting Part, showing Superficial 

Muscles of Perineum (Bumme). 


In the first stage of labor the bag of waters takes part in the dilata¬ 
tion and distention of the upper portion of the vagina, but after its 


Urethra Clitoris 


Vagina 
















282 


THE FORCES CONCERNED IN LABOR 


rupture the changes occurring in the pelvic floor are due entirely to the 
pressure exerted by the presenting part. As this descends, the anterior 
portion of the pelvic floor becomes forced against the inferior and pos¬ 
terior portions of the symphysis. On the other hand, the posterior 
portion undergoes marked changes, becoming pushed downward and 
forward, and subjected to great stretching, eventually being converted 
into a thin-walled, tubular structure—the perineal gutter. Fig. 239 
gives a good idea of the changes occurring in the pelvic floor, and demon¬ 
strates the important part played by the levator ani and the altogether 



Fig. 241.—Frozen Section, showing Condition of the Birth Canal in First Part of 

Second Stage of Labor (Braune). X 


insignificant function of the superficial perineal muscles. When the 
head distends the vulva, its opening looks upward and forward, and the 
course of the birth canal along the pelvic floor follows the curve indicated 
in Figs. 223 and 241. 

Webster has pointed out that the most marked change consists in the 
stretching of the fibers of the levator ani muscle and the thinning of the 
central portion of the perineum, which becomes transformed from a 
wedge-shaped mass of tissue 5 centimeters in thickness to a thin, almost 
transparent membranous structure 2 to 4 millimeters thick. At the 
same time it is pushed down about 2.5 centimeters from its original 
position. 

When the perineum is distended to the utmost, the anus becomes 
markedly dilated, and presents an opening which varies from 2 to 2.5 











LITERATURE 


283 


centimeters in diameter, through which the anterior wall of the rectum 
is seen to bulge. 


LITERATURE 

Aschoff. Das untere Uterinsegment. Zeitsckr. f. Geb. u. Gyn., 1906, lviii, 328- 
332. 

Ueber die Berechtigung, etc., des Begriffes Isthmus uteri. Verb. d. deutscken 
path. Gesellsch., 1908, xii, 314-322. 

Bandl. Ueber Ruptur der Gebarmutter. Wien, 1875. 

Ueber das Verhalten des Uterus und Cervix, etc. Stuttgart, 1876. 

Barbour. Atlas of the Anatomy of Labour Exhibited in Frozen Sections. 3d 
ed., Edinburgh, 1896. 

Is There a Lower Uterine Segment? J. Obst. and Gyn. British Empire, 1908, 
xiii, 237-248 and 315-327. 

Bayer. Zur physiol, und path. Morphologie der Gebarmutter, in Freund’s Gyn. 
Klinik. Stuttgart, 1885. 

Uterus und unteres Uterinsegment. Archiv f. Gyn., 1897, liv, 13-71. 

Braune. Die Lage des Uterus und Fotus am Ende der Schwangexschaft. Leipzig, 
1872. 

Braune und Zweifel. Gefrierdurchschnitte durch den Korper einer Hochschwang- 
eren. Leipzig, 1890. 

Bumm u. Blumreich. Gefriei durchschnitt, etc. Wiesbaden, 1907. 

Chiari. Ueber die topographischen Yerhaltnisse des Genitales einer intrapartum 
verstorbenen Primipara. Wien, 1885. 

Dickinson. Studies of the Levator Ani Muscle. Amer. Jour. Obst., 1889, xxii, 
897-917. 

Duncan. On the Length of the Cervix Uteri in Advanced Pregnancy. Researches 
in Obstetrics, Edinburgh, 1868, 243-273. 

Farabeuf. Les vaisseaux sanguins des oxganes genito-urinaires. Paris, 1905, 
p. 32. 

von Franqu^:. Cervix und unteres Uterinsegment. Stuttgart, 1897. 

Untersuchungen und Erorterungen zur Cervixfrage. Wurzburg, 1899. 

Grasel. Beitrage zur Frage des sogenannten unteren Uterinsegmentes. Zeitschr. 
f. Geb. u. Gyn., 1911, lxix, 581-620. 

Hofmeier. Das untere Uterinsegment in anat. und klin. Beziehung. Schroeder’s 
Der schwangere und kreissende Uterus. Bonn, 1886, 21-74. 

Holst. Beitrage zur Geburtshiilfe u. Gynakologie, 1865, Heft I, 130-169. 

Kustner. Das untere Uterinsegment und die Decidua cervicalis. Jena, 1822. 

Lahs. Zur Mechanik der Geburt. Marburg, 1869; Berlin, 1872. 

Die Theorie der Geburt. Bonn, 1877. 

Langhans und Muller. Weiterer anat. Beitrag zur Frage vom Verhalten der 
Cervix wiihrend der Schwangerschaft. Archiv f. Gyn., 1879, xiv, 184-189. 

Leopold. Uterus und Kind. Leipzig, 1897. 

Lott. Zur Anatomie u. Physiologie der Cervix uteri. Erlangen, 1872. 

Lusk. The Science and Art of Midwifery, 1895, 82. 

Martin. Der Haftapparat der weibl. Genitalien. Berlin, 1911. 

Mauriceau. Traite des maladies des femmes grosses, etc. 6me ed., 1721, t. i, 97. 

Muller, Untersuchungen liber die Verkiirzung der Vaginalportion, etc. Scan- 
zoni’s Beitrage, 1868, v, 191-346. 

Olshausen. Beitrag zur Lehre vom Mechanismus der Geburt. Stuttgart, 1901. 

Paramore. The Pelvic Floor Aperture. Jour. Obst. and Gyn. Brit. Emp., 1910, 
xviii, 95-121. 









284 


THE FORCES CONCERNED IN LABOR 


Pinard et Varnier. Etudes d ’anatomie obstetricale normale et pathologique. 
Paris, 1892. 

Roederer. EJementa artis obstetrician. Gottingae, 1766, 26. 

Ruge. Unteres Uterinsegment u. cervikale Umanderung. Zeitschr. f. Geb. u. Gyn., 
1906, lvii, 294-313. 

Saxinger. Gefrierdurchsehnitt einer Ivreissender. Tubingen, 1888. 

Schatz. De,r Geburtsmachanismus der Kopfendlagen. Leipzig, 1868. 

Beitrage zur physiologischen Geburtskunde. 1871. 

Schmidt. Anat. Untersuchungen zur Frage des unteren Uterinsegmentes. Zeit¬ 
schr. f. Geb. u. Gyn., 1922, lxxxv, 233-291. 

Sciiroeder. Der schwangere und kreissende Uterus. Bonn, 1886. 

Stoltz. Considerations sur quelques points relatif a l’art des accouckements. 
These de Strasbourg, 1826. 

Studdiford. The Involuntary Muscle Fibres of the Pelvic Floor. Am. J. Obst., 
1909, lx, 21-31. 

Taylor. On the Cervix Uteri. Amer. Med. Times, 1862, June 21. 

Varnier. Le col et le segment inferieur a la fin de la grossesse, etc. Paris, 1888. 
Veit. Unteres Uterinsegment und Cervixfrage. Verh. der deutschen Gesell. f. 
Gyn., 1899, viii, 430-449. 

Das untere Uterinsegment. Zentralbl. f. Gyn., 1914, 1369-1375. 

Waldeyer. Medianschnitt einer Hochschwangeren bei Steisslage des Fotus. Bonn, 
1886. 

Warnekros. Scliwangerschaft und Geburt im Roentgenbilde, Miinchen, 1921. 
Webster. The Female Pelvic Floor. Researches in Female Pelvic Anatomy 
Edinburgh, 1892, 93-112. 

Winter. Zwei Medianschnitte durch Gebarende. Berlin, 1889. 

Zweifel. Zwei neue Gefriersehnitte Gebarender. Leipzig, 1893. 

Ueber das untere Uterinsegment. Zentralbl. f. Gyn., 1914, 1376-1382. 


CHAPTER XII 


MECHANISM OF LABOR IN VERTEX PRESENTATIONS 

Vertex presentations occur in from 95 to 97 per cent, of all cases—■ 
94.6 per cent, in 7,000 consecutive cases in my service—and in them, as 
was first pointed out by Naegele, the sagittal suture nearly always en¬ 
gages in the right oblique diameter of the pelvis. In other words, one 
usually has to deal with a left occipito-anterior or a right occipito-pos- 
terior presentation. That this is so, and that the first-mentioned pres¬ 
entation is the one most frequently observed, all the authorities are 
agreed; but that wide differences of opinion exist as to the relative 
frequency of the several other varieties is clearly shown by the following 
table: 



Dubois in 1,913 cases. 

Pinard in 500 cases. 

The author in 6,877 cases. 1 

L. O. A. .r^-T. 

71 per cent 

52.6 per cent. 

54.08 per cent. 

L. O. P. . . 

.63 

11 

9.14 

R. 0. A. 

2.87 

.2 

25.09 

R. 0. P. 

25.6 

38.8 

11.68 


E. D. Plass, upon analyzing the incidence of the several varieties in 
5,445 vertex presentations in my service, gives the following figures: 

L. 0. A., 47.8; L. 0. T., 12.9; and L. 0. P., 3.3 per cent. 

R. 0. A., 19.1; R. 0. T., 8.9 ; and R. 0. P., 8.0 per cent. 

As many of our patients were not examined until late in labor, our 
figures do not adequately represent the initial incidence, as it is probable 
that a considerable proportion of the cases which are recorded as L. 0. T. 
or R. 0. T. originally entered the pelvis with the occiput obliquely pos¬ 
terior. That this inference is justified is shown by the fact that in 500 
cases from my private practice the L. 0. P. and R. 0. P. varieties were 
noted more than twice as frequently as in his series. Statistics of German 
authorities are not available for comparison, as they usually only indicate 
whether the occiput is directed toward the left or right side of the 

mother, and do not distinguish between the several varieties. Thus, 

Zweifel, in 9.351 vertex presentations, found the occiput directed to the 
left in 71.1 and to the right in 28.9 per cent., as compared with 64 and 
36 per cent,, respectively, in our series. 

Mechanism in Left and Right Occipito-anterior Presentations.—We 
shall consider in the first place the mechanism of labor in the anterior 
varieties of vertex presentations—namely, the left and right occipito¬ 
anterior. 


285 












280 MECHANISM OF LABOR IN VERTEX PRESENTATION 


Diagnosis .—The mode of presentation of the foetus is most reliably 
determined by abdominal palpation, which can be utilized not only 
during pregnancy but also at the time of labor, provided it be practiced 



Fig. 242.—Diagram showing Child in Fig. 243.—Diagram showing Child in 
L. O. A. R. O. A. 


in the intervals between the pains. Its accuracy, however, is markedly 
impaired in patients with very fat abdominal walls, or in whom the 
uterus is unduly distended by an excessive amount of amniotic fluid, or 



Fig. 244.—Frozen Section through Woman at End of Pregnancy, Child in R. O. T. 

(Zweifel). 


deformed by subperitoneal or intramural myomata, as the latter may 
occasionally be mistaken for portions of the child. 

For purposes of diagnosis we employ the four maneuvers already de¬ 
scribed, and with the foetus in the left occipito-anterior position obtain 
the following data: 










MECHANISM IN OCCIPITOANTERIOR PRESENTATIONS 289 


through the extremities of the fronto-occipital diameter. This normally 
measures 11.5 centimeters; and, as the eonjugata vera is only 11 centi¬ 
meters in length in the bony pelvis, and is encroached upon by various 
tissues in the living woman, it is apparent that a normal-sized head can¬ 
not engage with its sagittal suture directed anteroposteriorly. Accord¬ 
ingly, it must enter the superior strait either in the transverse or in 
one of its oblique diameters (12.75 centimeters). As has already been 
said, this usually occurs in the right oblique diameter, so that one end 
of the sagittal suture is directed toward the left iliopectineal eminence, 
and the other toward the right sacro-iliac synchondrosis. This is at¬ 
tributed to two factors. In the first place, the foetus, in the later months 
of pregnancy, tends to assume this position spontaneously; and secondly, 
the posterior end of the left oblique diameter is encroached upon by 
the rectum; so that, for practical purposes, it is shorter than the right. 

At first glance it may appear strange that the head does not engage 
in the transverse diameter of the pelvis, which measures 13.5 centimeters; 
but when one recalls the normal outlines of the superior strait (Figs. 247 




Figs. 247, 248. —Diagrams showing why the Head does not Enga^~ 

verse Diameter of the Superior Strata 

and 248), it is seen that this diameter extends on] ? ^rs 

in front of the promontory of the sacrum, so that fo A purposes 

the available transverse diameter is one which bisects Die eonjugata vera, 
and is more than a centimeter shorter than the oblique diameter. 

Prior to the middle of the eighteenth century little was known 
concerning the mechanism of labor, and it was generally thought that 
the head entered the pelvis with the sagittal suture directed antero¬ 
posteriorly. Fielding Ould in 1142 was the first to protest against such 
a view, and within the following thirty years the observations of Smellie, 
Saxtorph, and Solayres de Renhac demonstrated that enlargement oc¬ 
curred in the manner just described. It is true that Sentex, McKenon, 
Muller, and Martins have revived the older teachings, and have reported 
cases in which the head engages with the small fontanelle either just 
behind the symphysis pubis or just in front of the promontory of 
the sacrum—occipitopubic or occipitosacral presentation; but, inasmuch 
as in these circumstances labor is extremely difficult, it is evident that 
such an occurrence must be considered as distinctly pathological. 

Naegele in 1838 held that engagement took place in such a way 
that the sagittal suture assumed an eccentric position, being nearer the 












290 


MECHANISM OF LABOR IN VERTEX PRESENTATION 


promontory of the sacrum than the symphysis, and that therefore the 
anterior parietal bone of the foetus was first felt on vaginal examination— 
Naegele’s obliquity. Varnier, on the other hand, from the study of the 
various frozen sections at his disposal, concluded that the reverse was 
the case, and that the head entered the pelvis with its sagittal suture 
nearer the symphysis pubis, so that the posterior parietal hone was first 
felt on examination. 

Neither of these views is quite correct when the pelvis is normal and 
the uterus not pendulous. The first presupposes that the axis of the 
uterus is to be found somewhat in front of that of the superior strait, 
and the second that it lies posterior to it. It would seein that Varnier 

overlooked the fact 
that the cadavers upon 
which his conclusions 
were based were frozen 
in the horizontal posi¬ 
tion, when the flaccid 
uterus would rest upon 
the vertebral column. 
In the living woman, 
however, such condi¬ 
tions do not obtain, as 
the uterus rises with 
each contraction, when 
its long axis cor¬ 
responds more or less 
closely with that of the 
superior strait. More¬ 
over, careful vaginal 
examination reveals 
the fact that the head 
usually engages in 
such a manner that its sagittal suture lies either in the middle of the 
pelvis or approaches the promontory of the sacrum but slightly, but not 
by any means to the extent that Naegele had supposed. On the other 
hand, the condition of affairs noted by Varnier obtains only when con¬ 
siderable disproportion exists between the size of the head and the pelvis. 

Descent .—The first requisite for the birth of the child is descent, 
whose extent varies materially according as the patient is a primipara 
or a multipara. In the former, when there is no disproportion between 
the size of the head and the pelvis, engagement is already so deep at the 
onset of labor that the most dependent part of the head is at, or only 
slightly above, the level of the ischial, spines, so that descent does not 
begin until the second stage of labor sets in. In multiparae, on the 
other hand, descent begins with engagement, hut is most pronounced 
during the second stage. It should, however, be remembered that in 
either event once having been inaugurated descent is inevitably associated 
with the various movements to which reference will be made. Descent 
is brought about by one or more of four forces: (1) Intra-uterine fluid 









MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 291 


pressure; (2) direct pressure of the fundus upon the breech; (3) con¬ 
traction of the abdominal muscles, and (4) ^extension and straightening 
Df the child’s body. 

%J 

4 he X-ray studies of Warnekros show that during the first stage of 
labor the back of the child is markedly convex, but becomes straightened 
out during the second stage. This he considers affords conclusive evi¬ 
dence that the expulsive force exerted by the uterus is transmitted 
through the vertebral column of the child; while Sellheim contends that 
this is not the case, and that only fluid pressure is involved, as he holds 
that even after rupture of the membranes sufficient fluid is retained 
within the uterus to make it possible. 

As the anterior surface of the sacrum and the posterior surface of 



Fig. 250. —Frozen Section, Second Stage of Labor, Child in R. O. A., Membranes 
Unruptured (Braune). Compare with Fig. 244. 


the symphysis measure 12 and 5 centimeters, respectively, it is apparent 
that, if all parts of a body passing through the pelvic cavity are to reach 
the inferior strait at the same time, the one lying posteriorly must de¬ 
scend much more rapidly than the anterior portion. This compensatory 
difference in the rate of descent of the -portions of the presenting part 
occupying the anterior and posterior segments of the pelvis is known 
as sy?iclitism , and is clearly illustrated in Fig. 249. 

Flexion .—As soon as the descending head meets with resistance, 
whether it be from the margins of the superior strait or the_cervix, the 
walls of the pelvis or the pelvic floor, flexion result's. In this movement 
the head rotates about its transverse axis in such a manner as to bring 
the chin into more intimate contact with the thorax, thereby substituting 
the suboccipitobregmatic for the fronto-occipital diameter. 









292 


MECHANISM OF LABOR IN VERTEX PRESENTATION 


This purely mechanical phenomenon, by which a diameter of S 
replaces one of 11.75 centimeters, is due to the manner in which the he; 
is articulated with the vertebral column, whereby the former represen 
a two-armed lever, the short arm extending from the occipital condyl 



Fig. 251. 



Fig. 252. 





li 





1 


Figs. 251, 252. —Diagrams showing Effect of Flex- Fig. 253. —Diagram showin 

ion, Conversion of Occipitofrontal into Sub- Head Lever (America 
OCCIPITOBREGMATIC DIAMETER. Text-Book). 


to the occipital protuberance, and the long arm from the same poin 
to the chin (Fig. 253). It is therefore apparent that when resistanc 
is encountered the long arm of the lever, following the ordinary laws o 
mechanics, must ascend, while the short arm descends, and thus flexioi 
is brought about. 

The point of the birth canal at which this movement occurs varie; 




Fig. 254. —Diagram showing Anterior Fig. 255. —Diagram showing Anterior 
Rotation from L. O. A. Rotation from R. O. A. 


greatly. When there is no disproportion between the presenting part 
and the pelvic canal pronounced flexion does not occur until the resist¬ 
ance of the pelvic floor is encountered, but if descent begins before the 
external os is fully dilated, especially if its margins are resistant, flexion 



















MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 293 


. 

nay be completed before the head has left the uterus; while in generally 
•ontracted pelves the movement occurs in an exaggerated manner while 
engagement is being effected. 

Internal Rotation .—By this is understood a turning of the head about 
ts vertical axis in such a manner that the occiput gradually moves from 
he position which it originally occupied toward the symphysis pubis or 
he hollow of the sacrum, as the case may be. 

Internal rotation is absolutely essential for the completion of labor, 
except when the child is abnormally small, and in the anterior varieties 
ilways occurs from left to right in left positions, and in the reverse 
lirection in right position (Figs. 254 and 255). Indeed, no matter 
vhat the original position of the head may be, the occiput usually rotates 
;o the front, although exceptionally, in occipitoposterior presentations, 
it may turn toward the hollaw_of Jhe sacrum. It should be remembered 
that internal relation does not occur by itself, but is always associated 
with the descent of the presenting part. 

Various theories have been advanced in the attempt to explain the 
manner in which internal rotation is brought about, and a vast litera¬ 
ture has accumulated upon the subject, which was well reviewed by 
\ Paramore in 1909. Prior to the time of Ould and Smellie nothing was 
known concerning this movement, but afterwards it was believed that it 
was rendered necessary by the shape of the pelvic canal, it having been 
i taught that the superior strait represented an ellipse whose long axis lay 
C( transversely, and the inferior strait one whose long axis was anteropos- 
): terior; so that for the head to descend it was necessary that its sagittal 
, suture be directed transversely 
or obliquely to pass through the 
1; former, and anteroposteriorly to 
pass through the latter. A little 
consideration, however, will 
show that this is not the case, 
for, when the coccyx is displaced 
backward during labor, the in¬ 
ferior strait presents an almost 
circular opening, its transverse 
diameter being 11 and its an¬ 
teroposterior 11.5 centimeters. 

Yarnier was therefore justified 
in concluding that the shape of 
the pelvis alone does not explain 
the production of this move¬ 
ment. Moreover, when we recall 
the fact that it is the suboccipito-frontal circumference of the head which 
passes through the pelvic outlet, and that its greatest diameter measures 
only 10.5 centimeters (Fig. 256), it is evident that unless some other 
factor were concerned internal rotation would not be necessary. 

This factor is to he found in the structures of the pelvic floor, and 
particularly in the levator ani muscle, which, yielding before the impact 
of the head, nevertheless exerts sufficient force upon it to compel it to 



Fig. 256. —Diagram showing Suboccipito- 

BREGMATIC, SlIBOCCIPITOFRONTAL, AND OC¬ 
CIPITOFRONTAL Diameters. 












294 MECHANISM OF LABOR IN VERTEX PRESENTATION 

adjust itself to its curvatures. Furthermore, the walls of the perinea 
gutter offer a concave inclined plane over which the rounded head readil; 
glides in its downward course. 

This explanation, although fairly satisfactory when the occiput i 
originally directed obliquely anteriorly in the pelvis, would not neces 
sarily seem to apply with equal force to those cases in which it occupie 
an obliquely posterior position. But the following account of Dubois’, 
experiment clearly demonstrates that even in such circumstances th< 
pelvic floor exerts a predominating influence in the production of this 
movement: “In a woman who had died a short time previously in child j 
bed the uterus, which had remained flaccid and of large size, was opener 
up as far as the cervical orifice and held by assistants in a suitable post j 
tion above the superior strait. The foetus of the woman was ther 
placed in the soft and dilated uterus in the right occipitoposterior posi- 



Fig. 257. —Frozen Section through Woman in Labor with Child Partly delivered 
showing Complete External Rotation of the Head and Imperfect Rotation of 
the Shoulders (Zweifel). 


tion. Several pupil-midwives, pushing the foetus from above, readily 
caused it to enter the cavity of the pelvis. Much greater force was 
needed to make the head travel over the perineum and clear the vulva, 
and it was not without astonishment that we saw, in three successive 
attempts, that, when the head had traversed the external genital organs, 
the occiput had turned to the right anterior position, while the face 
was turned to the left and to the rear. In a word, rotation had taken 
place as in natural labor. We repeated the experiment a fourth time, but 
as the head cleared the vulva the occiput remained posterior. We then 
took a dead-born foetus of the previous night, but of much larger size 
than the preceding, and placed it in the same position as the first, and 
twice in succession witnessed the head clear the vulva after having 
executed the movement of rotation. Upon the third and following essays 
delivery was accomplished without the occurrence of rotation. Thus 
the movement only ceased after the perineum and vulva had lost the 














MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 295 


j! resistance which had made it necessary, or at least had been the inciting 
:ause of its accomplishment.” 

From Solayres de Renhac (1771) to the present time, many authors, 
imong whom may be mentioned Scanzoni, Hodge, and Reynolds, have 
jsought to explain the production of rotation by calling attention to the 
( ;hape of the pelvic canal, and pointing out that the inclination of its 
vails—the inclined planes of the pelvis —serves to direct the occiput 
1(i interiorly. By others it was thought that the projecting ischial spines 
julso played a similar part by interposing an obstacle to posterior rotation. 

Schroeder believed that the movement was inaugurated by the body of 
he child rotating in such a way as to bring its back more to the front, 
j md that the head followed it. He considered that this was brought about 
, )y an attempt on the part of the uterus to assume its normal flattened 
j Rape, as its contents were expelled. He did not believe that the shoul- 
lers were rotated into a directly transverse position, but considered that 
Rey remained somewhat behind the occiput—30 degrees, according to 
Schatz—and that the partial rotation of the body merely inaugurated 
Rat of the head, which was completed by the action of other accessory 
‘actors. 

Olshausen and Bumm argued in favor of this theory, but do not seem 
o have adduced any additional evidence in its support. Warnekros, on 
he contrary, states that his X-ray plates show that rotation of the body 
Tequently precedes that of the head, but he is, nevertheless, inclined 
:o believe that the pelvic floor plays the predominant part in bringing 
it about. Even if such views are accepted as partially correct, it must 
be admitted that they fail to solve the entire problem ; as a flattening 
Df the uterine cavity cannot be invoked in explanation of the rotation 
3f the shoulders into the anteroposterior diameter following the expul¬ 
sion of the head. This must be regarded as a movement of internal 
rotation, just as well as that which the head had previously undergone, 
and must be brought about by identical causes; as it would seem im¬ 
probable that one factor would be concerned in the causation of one 
rotation, and a few minutes another factor would bring about the other. 
Furthermore, the frozen section of Zweifel through a woman, who had 
died just after the birth of the child’s head, shows that the shoulders had 
not yet rotated antero-posteriorly, and indicates that such a movement 
would be hampered, rather than facilitated, by a flattening of the uterus. 

In 1906 Sellheim made an important contribution to the subject, 
which was still further elaborated in 1913. He held that internal rota¬ 
tion, and indeed the entire mechanism of labor, is the inevitable conse¬ 
quence of definite physical laws, one of the most important of which is 
that whenever a cylindrical body of suitable size, which can be bent to a 
different extent in several locations, is forced through a curved cylindrical 
canal, it must necessarily rotate until the portion which is most readily 
bent adapts itself to the curvature of the canal. By studying newly born 
children, he demonstrated that in vertex presentations such bending 
occurs most readily in the cervical region, and thus tends to bring about 
extension; while in face presentations it occurs in the opposite direction 
and brings about flexion. Accordingly, in the former rotation must take 









296 MECHANISM OF LABOR IN VERTEX PRESENTATION 



place until the posterior portion of the neck adapts itself to the “knee 
of the birth canal, while in the latter the anterior portion of the necl 
must become so adapted, thus causing the occiput or chin to rotat 
anteriorly, as the case may be. 


/ ockwood j e c 


Fig. 258.—Diagram showing Delivery of Head in Vertex Presentation. 


By a series of ingenious experiments he has shown that rotatio: 
always occurs in accordance with this law, and that it makes no differ 
ence whether the presenting part enters the pelvic canal in an oblique! 



Fig. 259. Diagram showing Delivery of Head in Vertex Presentation. 

anterior or posterior position. Unfortunately, Sellheim’s explanatioi 
has only carried us one step further forward, and still leaves us ii 
ignorance of the ultimate cause of the movement. 

Extension. —When, after internal rotation, the sharply flexed heac 














MECHANISM IN OCCIPITOANTERIOR PRESENTATIONS 297 


reaches the vulva, it undergoes another movement which is absolutely 
essential to its birth—namely, it becomes so extended that the base of 
the occiput comes in direct contact with the interior margin of the 
symphysis pubis. This movement is brought about by two factors. In 
the first place, as the vulval outlet looks upward and forward, extension 
must occur before the head can pass through it. For if the sharply 
Hexed head, on reaching the pelvic floor, continued to be driven down¬ 
ward in the same direction as heretofore— in the axis of the superior 
strait—it would impinge upon the end of the sacrum and the posterior 
portion of the perineum, and, if the vis a tergo were sufficiently strong, 
would eventually be forced through the perineal tissues. But when the 
head presses upon this structure, two forces come into play, the first 
acting downward, exerted by the uterus, and the second upward, supplied 



Fig. 260. —Diagram showing Delivery of Head in Vertex Presentation. 

by the resistant pelvic floor, the resultant force being one directed 
forward and somewhat upward in the direction of the vulval opening, 
thereby giving rise to extension. Joseph Jones in 190G directed atten¬ 
tion to the fact that the movement of extension does not occur merely 
at the articulation between the occiput and atlas, but is preceded and 
inaugurated by an extension of the entire cervical region. He holds that 
such a movement brings about a marked change in the manner in which 
the force exerted by the uterus is transmitted to the occiput, and likens 
it to the interposition of the crank shaft between the end of the piston 
and the wheel of an engine. 

After the suboccipital region has come in contact with the inferior 
margin of the symphysis pubis, the head is no longer to be regarded as a 
two-armed, but simply as a one-armed lever, the occiput being the ful¬ 
crum with the arm extending from it to the chin, so that any force 
exerted upon the head must necessarily lead to farther extension. As 
this becomes marked, the vulval opening gradually dilates and the scalp 








298 


MECHANISM OF LABOR IN VERTEX PRESENTATION 


of the child becomes apparent through it. Now, if we mark the point 
which first appears, and carefully examine the child after its birth, 
we find in left occipito-anterior presentations that it was the upper and 
posterior margin of the right parietal bone that first came into view, 
while the reverse holds good in right occipito-anterior positions. 

With increasing distention of the perineum and vaginal opening, a 
larger and larger portion of the occiput gradually appears, and the head 
is born by further extension, the occiput, bregma, forehead, nose, moufh, 
and finally the chin successively passing over the anterior margin of the 
perineum. Immediately after its birth the head falls downward and 
the chin comes in contact with the region of the anus. 

External Rotation .—A few moments after its birth the head under¬ 
goes another movement, and, when the occiput has been originally 
directed toward the left, it rotates toward the left tuber ischii, and in 
the opposite direction when it has been originally toward the right. This 




Fig. 261. Diagram showing child in Fig. 262. —Diagram showing Child in 
L. O. P. r. o. P. 

is known as external rotation or restitution, and is simply the index of a 
corresponding rotation of the body of the child, which serves to bring 
its bisacromial diameter into relation with the anteroposterior diameter 
of the pelvic outlet. This movement is brought about by essentially the 
same factors which produce the internal rotation of the head. 

Expulsion .—Almost immediately after the occurrence of external 
rotation, the anterior shoulder appears under the symphysis pubis, and 
in a short time the anterior portion of the perineum becomes distended 
by the posterior shoulder, which is first born, being rapidly followed 
by the other. Finally, the body of the child is quickly extruded along a 
curved line corresponding to the axis of the lower part of the birth 
canal that is, with its upper side markedly concave and its low r er convex. 

Mechanism in Right and Left Occipitoposterior Presentations._In 

5,488 cases of labor at the Johns Hopkins Hospital, in wdiich the vertex 
presented, we observed 635 occipitoposterior presentations (11.3 per 
cent.), the proportion in which the occiput was directed to the right or 
left being about 5 to 2. The number of primary occipitoposterior posi- 










MECHANISM TN OCCUTTOPOSTERIOR PRESEN CATIONS 299 


ions was probably twice as great as is here indicated, but, owing io the 
act that many of our patients were not examined until well advanced 
n the second stage of labor, it happened in many cases that anterior 
ol .ition had already occurred. 

Diagnosis .^-Palpation in a right oceipitoposterior presentation gives 
he following data: 

First maneuver: The fundus is occupied by the breech. 

Second maneuver: The resistant plane of the back is fell well back in the right 


flank, the small parts being on the left side and in front; 
and much more readily palpable than in anterior presen¬ 
tations. 


Third maneuver: Negative if the head is engaged; otherwise the movable head 

is detected above the superior stra : t. 

Fourth maneuver: Cephalic prominence on the left side (Plate XIX). 

Whenever the back of the child is felt on the right side of the 
mother, the possibility of a right posterior position should always be 
borne in mind, as it occurs much more frequently than the right 



Fig. 263. —Diagram showing Anterior Fig. 264. —Diagram showing Anterior 


Rotation from R. O. P. 


Rotation from L. O. P. 


anterior 'variety. It should also be remembered, whenever the small 
parts are distinctly felt in the anterior portion of the abdomen, 
that one has in all probability to deal with a posterior position, more 
especially in the rare instances in which the occiput has rotated into 
the hollow of the sacrum. In the less frequent left posterior positions 
palpation gives similar results, except that the back is felt in the left, 
flank, and the small parts and cephalic prominence are found on the 
right side of the abdomen. 

Ori vaginal or rectal touch in the right posterior position, the sagittal 
suture occupies the right oblique diameter, the small fontanelle is iej i 
opposite the right sacro-iliac synchondrosis, the large fontanelle being 
directed toward the left iliopectineal eminence; while in the left position 
the reverse In many cases, particularly in the early part of 

p .bor ow> • erfeet flexion of the head, ti e large fontanelle lies at 


n anterior positions, and is nnrp rendilv felt. 







300 MECHANISM OF LABOR IN VERTEX PRESENTATION 



On auscultation the heart is heard in the right or left flank of the 
mother, according as one has to deal with a right or left position. But 
it should be remembered that in the right posterior position the heart 
sounds are sometimes transmitted through the thorax of the child, and 
are best heard either in the middle line or slightly to the left of it. This 
is due,to a partial extension of the head and the altered relation oi ihe 
body of the child, whereby the thorax comes in contact with the anterior 
uterine wall. Failure to realize this possibility sometimes results in 
^serious diagnostic error. 

Mechanism .—In the great majority of occipitoposterior presentations 
the mechanism of labor is identical with that observed in the anterior 
varieties, except that the occiput has to rotate from the region of the 
sacro-iliac synchondrosis to the' symphysis pubis, instead of from the ilio- 


Fig. 265. —Diagram showing Posterior Fig. 266. —Diagram showing Posterior 
Rotation from L. O. P. Rotation from R. O. P. 

pectineal eminence—through 135 degrees instead of 45 degrees (Figs. 
263 and 264). 

In many instances internal rotation does not take place until the 
perineum begins to bulge, but occasionally it only occurs partially, or 
sometimes not at ail, so that the occiput rotates only to a transverse 
or an obliquely anterior position, or remains obliquely posterior. In 
either event spontaneous labor is out of the question unless the child 
is very small. Even in favorable cases consid arable time is usually re¬ 
quired for the completion of anterior rotation -so that there results a 
definite prolongation of labor. Yarnier, upon comparing the histories 
in 400 cases of occiput posterior and in 660 cases of occiput anterior 
presentation, found that, in the former, labor averaged three hours and 
sixteen minutes to one hour and fifty minutes longer, according as the 
patient was a primiparous or multiparous woman; although in my ex¬ 
perience the prolongation is not so great. 

In a small percentage of cases, particularly in women with funnel 
pelves, the occiput, instead of rotating anteriorly, or r<4a' it ^-original 

position, turns spontaneously toward the sacrum, sow •;? eventr 
occupies' its concavity. According to West and ^ 




•< r : i ' ' T OCCIPITOPOSTERIOR PRESENTATIONS 301 


* r ' - ' ■ i ■ of the cases, while we have noted it in a somewhat 

higher percentage of our obliquely posterior cases. 

In many instances it is difficult to explain why anterior rotation 





Fig. 267. —Usual Mechanism of Delivery of Head with Occiput in Hollow of 

Sacrum. 

fails to occur, but it may be stated as a general rule that it is much 
more likely to take place when the head is well flexed than when it 
is imperfectly flexed or partially extended. In the latter event the large 




Fig. 268. —Usual Mechanism of Delivery of Head with Occiput in Hollow of 

Sacrum. 

fontanelle occupies a lower level than the small, whence it would appear 
that it is usually the most dependent part of the head which rotates 
anteriorly. 

After the occiput has rotated into the hollow of the sacrum, the child 


















302 


MECHANISM OF LABOR IN VERTEX PRESENTATION 


may be born in one of two ways. Ordinarily the head becomes markedly 
flexed and lengthened in its mento-occipital diameter so that eventually 
the region just anterior to the large fontanelle impinges upon the lower 
margin of the symphysis pubis, after which the occiput is slowly pushed 
over the anterior margin of the perineum by a movement of flexion. 
Then by a movement *of extension the occiput falls backward, and the 
brow, nose, mouth, and chin appear successively under the symphysis. 
After the birth of the head, external rotation and expulsion of the body 
occur in the usual manner. 

According to Sentex, Winckel, Weiss, and Muller, the head is occa¬ 
sionally born by another mechanism, which comes into play in those 
cases in which partial extension persists. In such circumstances the 
brow appears at the vulva, and, while the root of the nose im ping es upon 
the symphysis, by a movement of H exion the brow, bregma, and occiput 
successively pass over the perineum, until finally the face slips" out fro m 
under the symphysis pubis. This mechanism approaches closely to that 
observed in brow presentations, and is much more difficult than the one 
just considered, and is more liable to lead to tears of the maternal soft 
parts, since it is evident that in the first instance the vulva is distended 
by the suboccipitofrontal circumference of the head, and in the second 
by the occipitofrontal, which measure 34 and 37 centimeters, respectively. 

It is generally believed that occipitoposterior offer a much more 
gloomy prognosis than occipito-anterior presentations. This is probably 
due to the fact that Mauriceau, Smellie, and all the early authorities 
taught that in such cases the occiput always rotated into the hollow of 
the sacrum, and that many later American writers, being led astray by 
their fears, have failed to realize what Nature can accomplish. It is 
true that Naegele showed that in the vast majority of cases the occiput 
rotated anteriorly, but in spite of his teachings, the older views still 
prevailed. Thus Capuron, in 1833, taught that spontaneous delivery 
could not take place; and Tarnier, while admitting the correctness of 
Naegele’s conclusions, nevertheless held that the prognosis was always 
serious, for, even when anterior rotation occurred, the duration of labor 
was markedly increased and the maternal and foetal mortality augmented. 

A comparatively large experience has led me to discount these 
gloomy views, and to regard the occurrence of posterior presentations 
with equanimity, provided the pelvis and child are normal in size. 
Moreover, in view of our uniformly good results, I do not consider it 
advisable to attempt to convert them into other positions during the 
course of labor, except when the forceps is to be applied. It is true that 
labor is somewhat prolonged, and instrumental interference is required 
more frequently—in 10 per cent, of the cases, according to Varnier, 
as compared with 3.6 per cent, in anterior presentations. In 635 of our 
cases, reported by Plass in 1916, in which delivery occurred spontane¬ 
ously or was aided by forceps, we had no maternal mortality attributable 
to the posterior position, and the foetal mortality was not appreciably 
increased over that occurring in obliquely anterior presentations. 

Even when the occiput rotates into the hollow of the sacrum, the 
prognosis is not bad, as in the majority of cases spontaneous delivery 







MECHANISM IN OCCIPITOPOSTERIOR PRESENTATIONS 303 


occurs, being noted by Yamier in 30 out of 35 cases. No doubt in such 
cases there is an increased tendency toward perineal tears, which is 
particularly marked when the head is born by the less frequent mechan- 
But to my mind the main 


Fig. 269. 


ism 

cause of the dread in which 
posterior presentations are held 
is the fact that they frequently 
escape recognition, with the re¬ 
sult that the large number 
which rotate anteriorly and 
end spontaneously are over¬ 
looked, and only those cases 
are recognized in which the 
occiput remains obliquely pos¬ 
terior or rotates into the hollow 
of the sacrum. Furthermore, 
the latter are usually not 
diagnosticated until operative 
interference becomes necessary, 
and even then not until re¬ 
peated failure at forceps ex¬ 
traction leads to careful exami¬ 
nation and, the recognition 
that the instrument had been 
applied improperly—that is, as 
in occipito-anterior presenta¬ 
tions. 

When in occipitoposterior 
presentations the head has de¬ 
scended into the pelvis, it is 
my practice to leave the case 
to Nature as long as possible, 
and to interfere only when ab¬ 
solutely necessary. But when 
convinced that the best inter¬ 
ests of the mother and child 
will be subserved by prompt 
delivery, forceps should be ap¬ 
plied according to the direc¬ 
tions which will be given in the 
appropriate chapter. On the 
other hand, when the head is 
arrested at the superior strait 
in a posterior position, version 
should be resorted to as soon as 
one is convinced that spon¬ 
taneous advance will not occur, provided, of course, that the operation 
is feasible and is not contra-indicated by disproportion between the size 
of the head and the pelvis. 


Fig. 270. 


Fig. 271. 

Fig. 269-271. —Caput Succedaneum at Birth; 
■ its Disappearance Three and Ten Days 
Later. 


304 


MECHANISM OF LABOR IN VERTEX PRESENTATION 


Changes in the Shape of the Head.—In vertex presentations the 
child’s head undergoes important and characteristic changes in shape, 
as the result of the pressure to which it is subjected during labor. In 
prolonged labors in which the membranes have ruptured before complete 
dilatation of the cervix, the portion of the head immediately over the 
os is relieved from the general pressure existing in the uterus, and, as a 
consequence, a serous exudate occurs under the scalp at this point, caus¬ 
ing a soft swelling, known as the caput succedaneum. Casually this 
attains a thickness of only a few millimeters, but in prolonged labors 
it may become very considerable and prevent the examining finger from 
distinguishing the various sutures and fontanelles. More usually the 
caput is formed when the head is in the lower portion of the birth 
canal, and frequently only after the resistance of a rigid vaginal outlet 
is encountered. It occurs upon the most dependent portion of the head, 
and therefore in left occipito-iliac positions is found over the upper 
and posterior extremity of the right parietal bone, and in right posi¬ 
tions over the corresponding area of the left parietal bone. Hence it 
follows that in many instances after labor we are enabled to diagnose 
the original presentation by the situation of the caput succedaneum. 

More important, however, are the plastic changes which the head 
undergoes. Owing to the fact that the various bones of the skull are 
not firmly united, movement may occur at the various sutures. Ordi¬ 
narily the margins of the occipital 
bone, and more rarely those of the 
frontal bone, are pushed under those 
of the parietal bones; and in many 
cases one parietal bone may overlap 
the other, the rule being that the 
one occupying the posterior position 
is overlapped by the anterior. These 
changes are of marked significance, 
especially in contrasted pelves, when 
the ability of the child’s head to be¬ 
come molded may make the difference 
between a spontaneous labor and a 
major obstetrical operation. 

As a result of pressure the head 
also undergoes a marked change in shape, which consists in a diminution 
of its suboccipitofrontal and occipitofrontal diameters. In other words, 
it becomes lengthened from chin to occiput and compressed in other 
directions. This is clearly shown in Fig. 272. 

In occipitoposterior presentations, when the occiput has rotated into 
the hollow of the sacrum, the frontal bone is markedly overlapped by 
the anterior margins of the parietal bones, which leads to a distinct 
depression of that part of the head, and gives some idea of the force 
with which the region of the large fontanelle has been pressed against 
the lower margin of the symphysis. 

Such pressure changes are of much more serious import than was 
formerly believed, and it is now known that they may play an important 



Fig. 272. —Diagram showing Config¬ 
uration of Head in Vertex Pres¬ 
entation (American Text-Book). 








LITERATURE 


305 


part in the production of fatal subdural hemorrhage. Holland, in his 
important work upon cranial stress during labor, has shown that they 
subject the tentorium cerebelli or the falx to excessive tension, which 
may result in actual lesions associated with hemorrhage, and which 
readily account for many foetal deaths which were formerly considered 
inexplicable. 

LITERATURE 

Bumm. Grundriss zuni Studium der Geburtshiilfe. 1905, 200. 

Capuron. Memoire sur Uimpossibilite de 1 ’accouchement naturel et la necessity 
du forceps dans les positions occipito-posterieures. Bulletin de 1 'Acad, de 
med., 1833, Nov. 2. 

Dubois. Quoted by Lusk. The Science and Art of Midwifery. New edition, 
1895, 175. 

Hodge. The Principles and Practice of Obstetrics. Philadelphia, 1866, 159-160. 
Holland. Cranial Stress in the Foetus during Labor. Jour. Obst. and Gyn. Brit. 
Emp., 1922, xxix, 549-571. 

Jones. Some Causes of Delay in Labor, with Special Reference to the Function 
of the Cervical Spine of the Foetus. Jour. Obst. and Gyn. Brit. Emp., 1906, 
x, 407-435. 

Martin. Die Aetiologie des hohen Geradstandes. Zeitschr. f. Geb. u. Gyn., 1915, 
lxxvi, 763-787. 

Mauriceau. Traite des maladies des femmes grosses, etc. 6me ed., Paris, 1721. 
McKerron. Antero-posterior Position of the Head as a Cause of Difficult Labor. 

Trans. London Obst. Soc., 1900, xli, 142-150. 

Muller, A. Ueber Hinterhauptslagen und Scheitellagen. Monatsschr. f. Geb. u. 

Gyn., 1898, vii, 382-399, u. 534-550. 

Naegele. Die Lehre vom Mechanismus der Geburt. Mainz, 1838. 

Olshausen. Beitrag zur Lehre vom Mechanismus der Geburt. Stuttgart, 1901. 

Zur Lehre vom Geburtsmechanismus. Zentralbl. f. Gyn., 1906, 1113-1119. 

Ould. A Treatise of Midwifery. Dublin, 1742. 

Paramore. A Critical Inquiry into the Causes of Internal Rotation of the Foetal 
Head. Jour. Obst. and Gyn. Brit. Emp., Oct., 1909. 

Pinard. Traite du palper abdominal. 2me ed., Paris, 1889, 27 and 37-44. 
Plass. A Statistical Study of 635 Labors with the Occiput Posterior. Bull. 

Johns Hopkins Hospital, 1916, xxvii, 164-177. 

Reynolds. Mechanism of Labor. Amer. Text-Book of Obstetrics, 1897, 384-492. 
Saxtorph. Theoria de diverso partu ob diversam capitis ad pelvim relationem 
mutuam. Havniae et Lipsiae, 1772. 

Gesammelte Schriften. Kopenhagen, 1803. 

Scanzoni. Lehrbuch der Geburtshiilfe, II. Aufl., Wien, 1853, 219. 

Schroeder. Lehrbuch der Geburtshiilfe, XIII. Aufl., 1899, 187-188. 

Sellheim. Die Beziehungen des Geburtskanales u. des Geburtsobjektes zur 
Geburtsmechanik. Leipzig, 1906. 

Die Geburt des Menschen. Deutsche Frauenheilkunde, 1913, Bd. I. 

Zur Auffassung von Warnekros iiber Geburtsmechanik. Monatsschr. f. Geb. 
u. Gyn., 1922, lviii, 237-249. 

Sentex. Etude statistique et clinique sur les positions occipito-posteiieures. 
Paris, 1872. 

Smellie. A Treatise on the Theory and Practice of Midwifery. Eighth edition, • 
London, 1774. 

Solayr^s de Renhac. Dissertatio de partu viribus maternis absoluto. Paris, 

1771. 




30G 


MECHANISM OF LABOR IN VERTEX PRESENTATION 


Tarnier. De 1 ’accouchement dans les occipito-posterieures. Seniaine med., Paris, 
1889, ix, 1. 

Varnier. De 1 ’attitude de la tete au detroit superieur et du mechanisme de son 
engagement. Annales d’obst. et de gyn., 1897, xlviii, 442-444. 

Accomodation de la tete fcetale au bassin maternal. Obstetrique journaliere, 
Paris, 1900, 131-149. 

Les occipito-posterieures. Obstetrique journaliere, 1900, 181-184. 

Warnekros. Schwangerschaft und Geburt im Roentgenbilde. Miinchen, 1921. 
Weiss. Zur Behandlung der Vorderscheitellagen. Volkmann’s Sammlung klin. 

Vortrage, N. F., 1892, Nr. 60. 

West. Cranial Presentations, etc. Glasgow, 1857. 

Winckel. Lehrbuch der Geburtshiilfe, II. Aufl., 1893, 147-150. 

Zweifel. Zwei neue Gefrierschnitte Gebarender. Leipzig, 1893. 

Erfalirungen an den letzten 10000 Geburten, etc. Archiv f. Gyn., 1914, ci, 
643-699. 





CHAPTER XIII 


MECHANISM OF LABOR IN FACE, BROW, AND BREECH 

PRESENTATIONS 

. 

Face Presentations.—In face presentations the head is sharply ex¬ 
tended, so that the occiput is in contact with the back, while the face 
looks downward. Markoe, and Pinard, upon analyzing 51,635 and 92,026 
cases of labor, found that the incidence of such presentations was 0.48 
and 0.4 per cent., respectively—that is, 1 to every 207 or 250 labors. 

Hie face most frequently occupies the right oblique diameter of the 
pelvis, so that the chin is directed either toward the left iliopectineal 



Fig. 273. —Diagram showing Position of 
Child in L. M. A. 



Fig. 274. —Diagram showing Position of 
Child in R. M. A. 


eminence or the right sacro-iliac synchondrosis. Accordingly, the left 
mento-anterior and right mentoposterior are the varieties usually ob¬ 
served, and together they constituted 62.4 per cent, of Markoeds 250 
cases. . 

It is generally stated that face presentations do not exist during 
pregnancy, but owe their origin to extension of the head at the superior 
strait at the onset of labor, although Mme. la Chapelle, Xaegele, 
Spiegelberg, Ribemont-Dessaignes, Fieux, and others have described in¬ 
stances in which they were diagnosticated during pregnancy. These are 
designated as primary, in contradistinction to the much more frequent 
secondary face presentations. 

Diagnosis .—In the left mento-anterior variety palpation gives the 
following data: 


307 











308 MECHANISM OF LABOR IN FACE AND BREECII PRESENTATIONS 


First maneuver: Breech in fundus. 

Second maneuver: Back in the right and posterior portion of the abdomen, and 

distinctly felt only in its upper portion; small parts in 
left and anterior portion of the abdomen. 

Third maneuver: Marked cephalic prominence on right side. 

Fourth maneuver: Marked cephalic prominence on right side; fingers can be 

depressed deeply on left. 

The reverse holds good in the right posterior variety (Plate XII). 
The characteristic sign is that the cephalic prominence is palpable on 
the same side as the back, the latter being distinctly felt only in the 
neighborhood of the breech. 

On vaginal or rectal touch the face is found in the birth canal, and 
the variety of presentation is diagnosticated by the differentiation of 
the various features, the mouth and nose, malar bones, and orbital ridges 
being the distinctive points. In the left anterior variety the chin occu¬ 
pies the anterior and the brow the posterior extremity of the right oblique 
diameter of the pelvis, while in right posterior position the reverse 
obtains. 

The heart sounds are transmitted through the thorax; accordingly 
they are heard through the side of the abdomen which contains the 
small parts and generally below the umbilicus. The only other condition 
in which auscultation gives similar results is in brow presentations 
and in the rare cases of occipitoposterior presentations in which the head 
is partially extended. 

Causation .—The causes of face presentations are manifold, and, 
roughly speaking, are afforded by any factor tending to bring about 
extension or to prevent--flexion of the head. Accordingly, they occur 
more frequently when the pelvis is contracted or the child very large. 
It is therefore an excellent practical rule to bear the latter possibility 
in mind whenever one meets with lack of engagement in a normal pelvis. 
Petit jean believes that the production of face presentation is favored 
by a low implantation of the placenta, which he has noted in two-thirds 
of the cases observed in Pinard’s clinic. 

To Matthews Duncan belongs the credit of having directed attention 
to the most frequent causative factor—namely, an oblique position of 
the uterus, which permits the child’s back to sag toward the side in 
which the vertex lies. He pointed out that in such circumstances the 
attitude of the foetus becomes distorted and abnormal, so that a slight 
obstacle to the descent of the posterior portion of the head will result 
in its extension. This occurs most frequently in right occipitoposterior 
presentations, as is shown by the fact that, while left occipito-anterior 
are many times more frequent than right occipitoposterior presentations, 
the same two varieties of face presentation occur with almost equal fre¬ 
quency. That multiparity would naturally favor the production of this 
condition is evident, since lax abdominal walls allow the uterus to assume 
an oblique position. Thus Pinard and Winckel state that 60 per cent, 
of their cases occurred in multiparous women. 

In exceptional instances, marked enlargement of the neck or thorax, 
coils of cord about the neck, or spastic contraction, or congenital shorten- 





PLATE XII 


r - 




First Maneuver. 


Second Maneuver. 




Third Maneuver. Fourth Maneuver. 


PALPATION IN RIGHT MENTO-ANTERIOR PRESENTATION 


HR™! 



































FACE PRESENTATIONS 


309 



ing of the cervical muscles may cause extension (Morse). Again, it is 
well known that hemicephalic children usually present by the face, as 
the result of the faulty development of the cranial vault. 

Hecker pointed out that face presentations are occasionally due to 
an elongation of the occipital portion of the head— dolichocephalus. 
There is no doubt that most children that are born by the face have 
heads of this character, but the fact that they usually resume their 
normal shape a few days after labor shows beyond question that the 

deformity is the result, rather than the 
cause, of the presentation. Zweifel delivered 
by cesarean section a dolichocephalic child, 
which had presented by the breech, and 
held that the observation demonstrated the 
possibility of the existence of a primary 
dolichocephalus; but Fritsch and most ob¬ 
servers contend that the peculiar shape of 
the head resulted from pressure exerted 
upon it by the fundus of the uterus. On 
the other hand, Jellinghaus and Gessner 
have reported cases which they believe sup- 


Fig. 275. —Tumor of Neck Fig. 276. —Dolichocephalic Head from 

causing Face Presenta- Breech Presentation (Jellinghaus). 

TION. 


port the original theory of Hecker; and, on the whole, it would seem 
probable that such a condition may occasionally bear a causal relation 
to face presentations. 

-*r Mechanism .—As face are usually derived from vertex presentations, 
it is apparent that the former are but rarely observed in a fully developed 
state at the superior strait, where the brow generally engages, while the 
face descends only after further extension. 

The mechanism in these cases consists of the cardinal movements— 
descent, internal rotation and flexion; and the accessory movements 
extension and external rotation. Descent is brought about by the same 
factors as in vertex presentations, while extension results from the rela¬ 
tion which the body of the child hears to its head, the latter being con¬ 
verted as it were into a two-armed lever, the longer arm of which extends 
from the occipital condyles to the occiput; so that when resistance is 
encountered the latter is pushed upward, while the chin descends (Fig. 
277). 







310 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 



Internal rotation has for its object the rotation of the face in such a 
manner as to bring the chin under the symphysis pubis, since otherwise 
natural delivery cannot be accomplished. Only in this way can the neck 
subtend the posterior surface of the symphysis pubis; whereas, if the 
chin rotates directly posteriorly, the relatively short neck cannot span 
the anterior surface of the sacrum, which measures 12 centimeters in 
length, so that the birth of the head is manifestly impossible unless the 
shoulders can enter the pelvis at the same time, which is out of the 
question except when the child is very small or premature (Fig. 278). 
Internal rotation is due 
to the same factors as 
in vertex presentations, 
and Sellheim holds that 
as bending in face pres- 


Fig. 277. —Diagram showing Fig. 278. —Diagram illustrating Impossibility of La- 
that in Face Presenta- bor in Face Presentations when the Chin has 
tions the Occiput is the rotated Directly Posterior. 

Long End of Head Lever. 

entations occurs most readily between the anterior surface of the neck 
and the chin that portion of the child must inevitably rotate to the front 
so as to accommodate itself to the "knee” of the birth canal. 

After anterior rotation the chin and mouth appear at the vulva; 
the under surface of the chin becomes stemmed against the symphysis, 
and the head is delivered by a movement of flexion, the nose, eyes, brow, 
bregma, and occiput appearing in succession over the anterior margin of 
the perineum (Figs. 280, 281, 282). After the birth of the head 
the occiput sags backward toward the anus, and in a few moments the 
chin, by a movement of external rotation, turns to the side toward which 
it was originally directed, after which the shoulders are born as in vertex 
presentations. 

In a small number of cases internal rotation, instead of occurring 
anteriorly, may take place toward the hollow of the sacrum, or, occa¬ 
sionally, as was pointed out by Hodge, the face may engage primarily 
in this manner. In such circumstances, for the reasons given above, 
the birth of a normal-sized child is usually impossible. Reed, in 1905, 










FACE PRESENTATIONS 


311 




has shown that such a view is somewhat too extreme, for, after reviewing 
75 cases of persistent mentoposterior presentations reported in the litcra- 




■ * ^ 

■■ ' 


- 




locKWOoAa 4c. 


Fig. 280. —Diagram showing Delivery of Head in Face Presentation. 


are not very serious, as in the entire series 11.6 per cent, of the mothers 
and 40.6 per cent, of the children perished, in spite of attempts at de¬ 
livery by various methods. 


/- OCA'\/i/b ' 


Fig. 279. —Distention of Vulva jn Face Presentation (modified from Ahlfeld). 


ture, he found that 17 had been delivered without change of presentation. 
This, however, should not be taken as indicating that such positions 



























312 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


In mental presentations the face becomes distorted owing to the effu¬ 
sion of serum beneath the skin, which when marked completely obliter¬ 
ates the features and may readily cause confusion with a breech presenta¬ 
tion. At the same time the skull undergoes considerable molding, which 



Fig. 281. —Diagram showing Delivery of Head in Face Presentation. 

is manifested by an increase in length of the mento-occipital diameter 
and a diminution in the vertical diameters of the head. 

Prognosis .—Until the latter part of the eighteenth century face pres¬ 
entations were considered extremely unfavorable, and most authorities 


Fig. 282. —Diagram showing Delivery of Head in Face Presentation. 

advised their conversion into some other variety. But about that time 
Deleurye, in France, and Zeller and Boer, in Austria, pointed out that 
most of them would end spontaneously if left alone. This doctrine was 
established by the last named author, who stated that he had observed 















FACE PRESENTATIONS 


313 




Fig. 283. —Showing Distortion of 
Face after Delivery in Face 
Presentation. 


spontaneous labor in 79 out of 80 face presentations, and had applied 
forceps in only a single instance. 

Deep tears of the perineum are of frequent occurrence, and are 
ofttimes erroneously attributed to excessive distention of the vulval out¬ 
let by the largest circumference of the head—the mento-occipital. In 
reality, however, the trachelobregmatic 
is the circumference concerned, and as 
it is but little larger than the subocci- 
pitofrontal, which is concerned in vertex 
presentations, some other factor must 
be invoked to explain the greater in¬ 
cidence of perineal tears. This probably 
consists in the greater forward pro¬ 
trusion of the pelvic floor, as in face 
presentations the presenting part must 
descend very deeply before flexion of 
the neck under the symphysis can occur. 

Owing to the prolongation of labor 
the foetal mortality is markedly in¬ 
creased, being usually estimated at about 
14 per cent. Markoe’s mortality was 
21 per cent., while Weiss lost only 4 
out of 78 children (5.1 per cent.). 

In dealing with face presentations it should always be borne in mind 
that internal rotation does not occur until the pelvic floor is well dis¬ 
tended by the advancing face; and frequently, when the chin is obliquely 
posterior, it may not take place until the obstetrician has almost aban¬ 
doned hope of its occurrence. Nor should it be forgotten that the face 
must occupy a lower level than the vertex before one can feel assured 

that the greatest circumference of 
the head has passed through the supe¬ 
rior strait. This can be readily ap¬ 
preciated from a study of Figs. 285 
and 286, in which it is seen that the 
distance from the parietal boss to the 
vertex is only 3 centimeters, whereas 
a line drawn from the same point to 
the face will measure 7 centimeters. 

Treatment .—In the anterior vari¬ 
eties spontaneous delivery is the rule, 
and, even when the chin is obliquely 
posterior, anterior rotation usually 
occurs, although often not until a 
very late period. In view of the 
serious prognosis attending failure of the chin to rotate anteriorly and 
particularly when the face rotates into the hollow of the sacrum, an 
attempt should be made to substitute a vertex presentation. When the 
head is not deeply engaged, provided there exists no disproportion be¬ 
tween the size of the head and the pelvis and the amniotic fluid has 


Fig. 284. —Diagram showing Config¬ 
uration of Head in Face Presen¬ 
tation (American Text-Book). 




314 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


not long since drained away, this can sometimes be readily accomplished, 
either by pushing up the chin or by making traction upon the occiput. 

On the other hand, when the chin is directed anteriorly, attempts at 
conversion are not advisable, as they would merely substitute an 
occipitoposterior position, which is but slightly more favorable than the 
original face presentation, not to speak of the increased danger of 
infection attending the manipulation. In obliquely posterior face posi¬ 
tions, on the contrary, conversion is urgently indicated, and should be 
attempted as soon as the condition is recognized and the degree of 
dilatation of the cervix permits. If it cannot be readily elfected, internal 
podalic version becomes the operation of choice. 

From time to time numerous methods of conversion have been sug¬ 
gested, the oldest and most effectual being the following, advocated by 



Fig. 285. —Diagram showing that when 

THE VERTEX IS ON THE LlNE JOINING 

the Ischial Spines, the greatest 
Diameter of the Head has Passed 
the Superior Strait. 



Fig. 286. —Diagram showing that when 
the Face is on the Level of the 
Ischial Spines, the Greatest Diam¬ 
eter of the Head is Still Above the 
Superior Strait. 


Baudelocque and revived by Thorn, Weiss, and others: Attempts are 
made to push up the chin by two fingers introduced into the vagina; if 
this does not succeed the patient is anesthetized, the whole hand intro¬ 
duced, and the head dislodged, after which the vertex is grasped and 
drawn down. At the same time the external hand of the operator or the 
assistant carries the back in the opposite direction, so as to facilitate flex¬ 
ion. Very excellent results have been obtained by this maneuver, and 
its adoption in suitable cases can be recommended. 

Schatz suggested the method of external manipulation, pictured in 
many text-books, by which the vertex is substituted for a presenting face. 
This, however, is rarely available, inasmuch as the presentation does not 
become well developed until after engagement has occurred. 

If the face be too deeply engaged in the pelvis to admit of the Baude¬ 
locque maneuver, the patient should be let alone and descent allowed to 
take place, in the hope that anterior rotation will occur when the face 
reaches the pelvic floor. If, however, this does not take place after a 
reasonable delay, and. symptoms supervene which indicate the termina¬ 
tion of labor, manual rotation should be attempted, and if this cannot be 







BROW PRESENTATIONS 


315 


effected forceps should be applied in the manner to be described later, 
and an attempt made to rotate the chin to an anterior position; finally, 
if this fails, the only resource lies in pubiotomy or craniotomy, as 
cesarean section should not be considered on account of its high ma¬ 
ternal mortality when done so late in labor. 

When the chin is originally situated directly posteriorly, or has 
rotated into that position, internal podalic version should be performed 
as soon as the condition of the cervix will permit, provided the head is 
not too deeply engaged or the uterus so tightly contracted about the 
child as to contra-indicate it. On the other hand, if the face be so 
firmly engaged that it cannot be pushed up under anesthesia, craniotomy 
or pubiotomy must be resorted to as soon 
as the patient's condition calls for de¬ 
livery. The former has been repeatedly 
practiced, and Morse has collected the 
few cases in which pubiotomy has been 
performed, including two successful 
operations- done in my clinic. 

Brow Presentations.—In brow pres¬ 
entations the head occupies a position 
midway between flexion and extension; 
hence the portion situated between the 
orbital ridge and large fontanelle pre¬ 
sents at the superior strait. As nearly 
every child which is born by the face 
has gone through a preliminary stage 
of brow presentation, the latter must 
occur more frequently, later undergoing 
spontaneous conversion into either a 
face or a vertex presentation. On the 
other hand, persistent brow presenta¬ 
tions are extremely rare, and are gen¬ 
erally stated to occur once in every 
1,500 to 2,000 cases, though Weiss and 
Markce observed one example in every 
1,000 cases. 

The causes of this presentation, which have been carefully studied by 
Ahlfeld, are practically identical with those giving rise to face presenta* 
tions, and depend upon any factor which interferes with flexion or 
promotes extension of the head. In twin pregnancies not infrequently 
one or both children may present in this manner, and Ahlfeld maintains 
that the anterior surfaces of the two foetuses coming in contact mutually 
disturb the normal flexed attitude, so that extension is facilitated. 
Usually the brow is directed toward one or other extremity of the right 
oblique diameter of the superior strait, and accordingly the left anterior 
and right posterior varieties are the ones most frequently encountered. 

Diagnosis .—The presentation can be recognized by palpation and 
vaginal touch, though the data obtainable from the former are less char¬ 
acteristic than in the more common presentations. The palpatory find- 



Fig. 287. —Diagram showing Di¬ 
rection of Pressure in Con¬ 
version of a Face into a Ver¬ 
tex Presentation by Thorn’s 
Maneuver. 





316 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


ings are similar to those observed in face presentations, except that the 
cephalic prominence is less marked on the side of the back, while the 
resistance offered by the chin can be felt on the same side as the small 
parts. On vaginal or rectal touch the frontal and the anterior portion 
of the sagittal suture are encountered in one of the oblique diameters, 
at one end of which the large fontanelle or the portion of the skull just 
posterior to it may be felt; while at the other the orbital ridges, the 
root of the nose, and the eyes may be distinguished. It is not possible 
to palpate the mouth or chin, for when these are within reach we have 
to deal with a face presentation. 

Mechanism .—The mechanism of labor in brow presentations differs 
materially with the size of the foetus. Ahlfeld and most observers have 
stated that this is most frequently below the normal; whereas Weiss 



Fig. 288. —Diagram showing Position 
of Child in Left Anterior Brow 
Presentation. 


Fig. 289. —Diagram showing Position 
of Child in Right Posterior Brow 
Presentation. 


maintains that large children are the rule. In the former case the course 
of labor as a rule is quite easy, while in the latter it is usually very 
difficult. The cause of the difficulty is apparent when we consider that 
the circumference of the head which must engage at the superior strait 
is the mento-occipital, whose greatest diameter averages 13.5 centimeters 
in length, and that engagement is therefore impossible until after marked 
molding has taken place, by which the mento-occipital diameter has be¬ 
come diminished and the fronto-occipital increased in length. 

After molding and descent have occurred the brow usually rotates an¬ 
teriorly, and the forehead, orbital ridges, and root of the nose appear at 
the vulva. One of the superior maxillary bones then becomes stemmed 
against the inferior margin of the symphysis, and the rest of the head is 
born by a movement of extreme flexion, the brow, bregma, and occiput 
appearing in succession over the anterior margin of the perineum. After 
the birth of the occiput, the mouth and chin descend from behind the 
pubic arch by a movement of extension. In other words, we have a 
mechanism somewhat similar to that observed in the less frequent mode 








BROW PRESENTATIONS 


317 


of delivery in the case of posterior occiput presentations which have 
rotated into the hollow of the sacrum. In very rare instances, as re¬ 
ported by Bretz and Zimmermann, birth may occur without internal 
rotation, with the frontal suture extending transversely. Such a mechan¬ 
ism occurs so rarely that it should be regarded as an obstetrical curiosity. 

As has already been pointed out, a large child cannot enter the birth 
canal without considerable molding of the head. This adds materially 
to the length of labor and results in the birth of children with charac¬ 
teristically deformed heads. The caput is found over the forehead and 
extends from the orbital ridges to the large fontanelle, and in many cases 
is so marked as to render diagnosis by vaginal touch almost impossible. 
In these cases, as is shown in Fig. 290, the forehead is very prominent 
and square, the mento-occipital 
diameter being diminished and the 
fronto-occipital diameter increased 
in length. 

Prognosis .—In the transient 
varieties of brow presentation, the 
outlook depends upon the presenta¬ 
tion which ultimately results, and 
whether the face or vertex enters 
the birth canal; while in the per¬ 
sistent forms it is generally con¬ 
sidered to be bad, unless the foetus 
be small. It should always be re¬ 
membered that disproportion be¬ 
tween the size of the head and the 

pelvis is an important factor in the production of such presentations, 
and that with a pelvis and head of the same size the possibility 
of a spontaneous outcome is always much less in a brow than in a vertex 
presentation. 

Rational methods of treatment, similar to those indicated in face 
presentations, and more particularly stricter attention to aseptic technic 
have led to a marked improvement in the prognosis of the persistent 
varieties. Thus, Markoe records a foetal mortality of 39 per cent., while 
Weiss, on the other hand, has reported 29 cases, without a death of foetus 



Fig. 290. —Diagram showing Configu¬ 
ration of Head in Brow Presenta¬ 
tion (American Text-Book). 


or mother. 

Treatment .—If the brow be recognized at the superior strait, the 
treatment will vary according as the presentation promises to be transient 
or persistent. The former should be left alone, as it will undergo spon¬ 
taneous conversion into a vertex or face presentation, and the child will 
probably be born spontaneously. On the other hand, in persistent cases, 
particularly if the brow be obliquely posterior, attempts at conversion 
should be made as soon as the first stage of labor is completed. If they 
are not successful, version should be performed, if feasible, as recom¬ 
mended in face presentations. If the brow be deeply engaged, conversion 
should not be attempted unless one is able to push the presenting part 
up to the level of the superior strait, when the treatment is identical 
with that outlined above. But if this cannot be accomplished, version 



318 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


is also out of the question, and the case should be left to nature, and 
forceps applied when indicated by the condition of the mother or child, 
and followed by craniotomy if necessary. It should be remembered, 
however, that delivery in these circumstances is nearly always associated 
with considerable injury to the maternal soft parts, owing to the large 
circumference of the foetal head by which they are distended. Wallich 
has made an earnest plea for the performance of symphyseotomy in per¬ 
sistent brow presentations, and has reported 7 operation with no ma¬ 
ternal and only 2 foetal deaths. In my opinion late cesarean section 
is rarely indicated, because of its high maternal mortality, and, if under¬ 
taken, should be followed by supravaginal hysterectomy. On the other 



Fig. 291. —Diagram showing Position of 
Child in L. S. A. 


Fig. 292. —Diagram Showing Position 
of Child in R. S. A. 


hand, if section is done early in labor it should be on account of the pelvic 
indication, rather than because of the abnormal presentation. 

Breech Presentations.—As has already been pointed out, the relation 
between the lower extremities and buttocks of the child is not always the 
same in sacro-iliac presentations, and we therefore distinguish between 
frank breech, complete breech, foot and knee presentations. In all these 
varieties, however, the mechanism of labor is essentially the same, so that 
they need not be considered separately. 

Usually the breech engages in such a manner that the sacrum is di¬ 
rected to the left side of the mother, and accordingly the left sacro¬ 
anterior or posterior are the positions most frequently observed. 

In 100,000 cases of labor Pinard observed 3,301 breech presentations 
—about 3.30 per cent. These statistics include premature as well as full- 
term labors, but, if the latter alone are considered, the incidence would 
be somewhat less. 

Diagnosis .—On palpation, the first maneuver reveals a hard, round, 
readily hallottable body occupying the fundus of the uterus, and when 
the abdominal w r alls are very thin one can occasionally obtain a charac¬ 
teristic cracking sensation upon compressing the bones of the skull. By 






PLATE XIII 



Third Maneuver. Fourth Maneuver. 

PALPATION IN LEFT SACRO-ANTERIOR PRESENTATION. 



































BREECH PRESENTATIONS 


319 


the second maneuver the back is found to occupy one side of the abdomen 
and the small parts the other, position and variety being determined by 
the location of the former. On the third maneuver, if engagement has 
not occurred, the irregular breech is freely movable above the superior 
strait; while, if it has already occurred, the fourth maneuver shows 
that the pelvis is filled by a soft mass which interferes with the penetra¬ 
tion of the fingers (Plate XIII). Kautsky has made the interesting 
observation that in breech presentations a distinct slowing in the foetal 
pulse rate can be elicited by compressing the head at the fundus between 
the fingers. 


In doubtful cases, the diagnosis may be established by means of the 



Fig. 293. —Frozen Section, Latter Part of Pregnancy, Child in L. S. T. (Waldeyr). 


X-ray, and in such circumstances it will usually be found that the head 
is less sharply flexed and that the arms occupy a much freer position 
than is generally taught. 

On vaginal or rectal examination the diagnosis of a frank breech 
presentation is made by recognizing its characteristic portions. Usually 
one can feel both tubera ischii, the sacrum with its spinous processes, 
and the anus, and when further descent has occurred the external 
genitalia may be distinguished. Especially where labor is prolonged, 
the buttocks may become markedly swollen, so that differentiation be¬ 
tween the face and breech may be rendered very difficult, as the anus 
may be mistaken for the mouth, and the ischial tuberosities for the 
malar bones. Care in examination, however, should prevent this error, 
for when the finger is introduced into the anus it experiences a muscular 










320 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


resistance, whereas in the mouth the firmer, more unyielding jaws would 
be felt. Again, on removing the finger, it is sometimes found to be 
stained with meconium, which could never occur with a face presentation. 
The most accurate information, however, is obtained from the sacrum 
and its spinous processes, for when these are felt the diagnosis of posi¬ 
tion and variety is established. 

In complete breech presentations the feet may be felt alongside of 
the buttocks, and in footling presentations one or both feet may hang 
down into the vagina. In the latter case, one can readily determine 
which foot is encountered by bearing in mind the relation of the great 
toe. When the breech has descended deeper into the pelvic cavity, the 
genitalia may be felt, and if these are not deformed by an effusion of 
serum it is possible to determine the sex of the foetus. Only in such 
circumstances can we feel certain as to this point before delivery. 



Fig. 294. —Diagram showing Direction of Internal Rotation in R. S. P. Position. 

The foetal heart sounds are heard through the back of the child, usu¬ 
ally at the level of the umbilicus or slightly above it. 

Etiology .—The causes of breech presentations are manifold. Ac¬ 
cording to the experiments of Schatz, the foetus, when suspended in 
liquor amnii, always sinks by its buttocks, so that, if gravity were the 
only factor concerned, breech presentations would be the most fre¬ 
quent of all. As a matter of fact, however, this is by no means the case. 

In the later months of pregnancy head presentations result from a 
process of accommodation between the foetal ovoid and the uterus; ac¬ 
cordingly, breech presentations are prone to occur when the process is 
interfered with. These factors do not so readily come into play in the 
earlier months, when breech presentations are much more common than 
at term. They are also frequently lacking in twin pregnancies and in 
cases of hydramnios, inasmuch as the increased distention of the uterus 
interferes with accommodation. According to Pinard’s statistics, 59 
per cent, of all breech presentations occur in multiparae, in whom the 







BREECH PRESENTATIONS 


321 


flaccidity of the uterine and abdominal walls plays a part in their pro¬ 
duction. Their occurrence is also favored by the presence of any 
obstacle which opposes the engagement of the vertex, as contracted pelvis, 
excessive size of the normal head, or hydrocephalus. 

Mechanism .—Unless there be some disproportion between the size of 
the child and the pelvis, engagement and descent readily occur in one of 
the oblique diameters of the pelvis, the anterior hip being directed toward 
one iliopectineal eminence, and the posterior hip toward the opposite 
sacro-iliac synchondrosis. The former usually descends more rapidly 
than the latter, and, when it encounters the resistance of the pelvic floor, 
internal rotation usually occurs and brings the anterior hip to the pubic 
arch, the bitrochanteric diameter of the child coming into relation with 



Fig. 295 .—Birth of Head in Breech Presentation. 


the anteroposterior diameter of the pelvic outlet. Rotation usually 
takes place from the iliopectineal eminence to the pubis through an arc 
of 45 degrees. If, however, the posterior extremity is prolapsed it always 
rotates to the symphysis pubis, rotation ordinarily occurring through 
an arc of 135 degrees, but occasionally it will take place in the opposite 
direction, the prolapsed hip rotating past the sacium and through the 
opposite half of the pelvis, through an arc of 225 degrees. Sellheim 
explains the latter phenomenon by assuming that the retained leg acts as 
a splint to the corresponding side of the body, with the result that it can¬ 
not so readily undergo the lateral flexion necessary to delivery as the 
side which is not so splinted. 

After rotation, descent continues until the perineum is distended by 
the advancing breech, while the anterior hip appeals at the vulva and is 
stemmed against the pubic arch. By a movement of lateral flexion of 
the body, the posterior hip is then forced over the anterior margin 
of the perineum, which retracts over the child, thus allowing its body 
to straighten out, when the anterior hip is born. The legs and feet 









322 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


follow the breech and may be born spontaneously, although the aid of 
the obstetrician is sometimes required. After the birth of the breech 
a slight moveemnt of external rotation occurs, and the back usually 
turns somewhat to the front, as the result of the shoulders being brought 
into relation with one of the oblique diameters of the pelvis. They 
then descend rapidly and undergo internal rotation, the bisacromial 
diameter now corresponding with the anteroposterior diameter of the 
inferior strait. Immediately following the shoulders, the head, which is 
normally sharply flexed upon the thorax, enters the pelvis in one of the 
oblique diameters, and then rotates in such a manner as to bring the 
posterior portion of the neck under the symphysis pubis, after which 
the head is born in a position of flexion, the chin, mouth, nose, forehead. 



Fig. 296. —Birth of Head in Breech Presentation. 


bregma, and occiput appearing in succession over the perineum (Figs. 
295 and 296). 

In a small number of cases rotation occurs in such a manner that the 
back of the child is directed toward the vertebral column, instead of 
toward the abdomen of the mother. In such circumstances the face 
appears under the symphysis pubis, the face, brow, and finally the occiput 
slipping down under it, as the head is born. It is of the utmost impor¬ 
tance to remember that if premature traction be employed the head may 
become extended, when its delivery can only be accomplished by the 
operation of extraction. 

Prognosis .—So far as the life of the mother is concerned, the prog¬ 
nosis differs hut slightly in breech and vertex presentations, except that 
with the former labor is slower, and in operative cases is more liable to 
be complicated by perineal tears, which sometimes extend through the 
sphincter ani muscle. The prognosis for the child, on the other hand, 
is considerably worse than in vertex presentations, the foetal mortality 



BREECH PRESENTATIONS 


323 


being generally estimated at 10 or 15 per cent. This figure applies to 
primiparous women, but a somewhat lower percentage obtains in multip¬ 
arous women. Porak states that 1 child in 9 succumbs in the former 
.* class of cases, as compared with 1 in 30 in the latter. 

The somber prognosis for the child is due to several factors. In the 
first place, after the breech is born as far as the umbilicus, the cord is 
exposed to a greater or lesser degree of compression between the head and 
the pelvic brim. It is usually stated that not more than eight minutes 
can elapse between the birth of the umbilicus and the delivery of the 
head, if the child is to be born alive. This is not quite correct, as a 
much longer time may elapse, provided the mouth has appeared at the 
vulva, thereby affording the possibility for the establishment of pul¬ 
monary respiration in case the circulation through the cord has been 
I cut off. 

Occasionally foetal death is due to the premature separation of the 
placenta, for, if the delivery is not promptly effected after the head has 
i passed into the lower part of the birth canal, the partially emptied uterus 
i may retract to such an extent as to separate the placenta from its walls, 
i and thus put a stop to the uteroplacental circulation. Holland, and 
\ Capon, in 1922, established the predominant cause of foetal death in 
’ breech presentations, by showing that the probability of the occurrence 
: of tentorial tears and subsequent intracranial hemorrhage is twice as 
| great as in head presentations. Furthermore, they have shown that 
[ when extraction is practiced, and especially when it is aided by supra¬ 
pubic pressure upon the head, the medulla may protrude through the 
foramen magnum and actually become herniated into the spinal canal. 

In primiparous women, where considerable resistance is offered by the 
pelvic soft parts, spontaneous delivery of the head is often unavoidably 
delayed and foetal death results, unless the child be extracted manually. 

Treatment .—In view of the serious foetal prognosis attending breech 
presentations, the obstetrician should aim to prevent their occurrence as 
far as possible, and whenever they are recognized in the later weeks of 
pregnancy an attempt should be made to substitute a vertex presentation 
by means of external version, unless there exists such disproportion 
between the size of the head and the pelvis as to make the occurrence of 
spontaneous delivery dubious. This is readily accomplished in multip- 
arae with lax abdominal walls, but is more difficult in primiparae. If 
the head can be forced into the pelvis after the substitution has been 
effected, the new position becomes permanent; but if this is not possible, 
the child will usually revert to its original position, notwithstanding 
the application of a properly fitting bandage. In the former case, the 
result is usually excellent, and affords striking proof of the value of 
routine ante-partum examination. External version may also be at¬ 
tempted in the first stage of labor, provided the breech has not descended 
deeply into the pelvis; but when it has once become fixed, all such efforts 
are unavailing. 

In most breech presentations spontaneous delivery occurs, and the at¬ 
titude of the obstetrician should be merely one of expectancy; neverthe¬ 
less, he should always hold himself in readiness to intervene at a mo- 





324 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS 


mentis notice. For this reason, as soon as the breech appears at the 
vulva, the patieni should he brought to the edge of the bed in order that 
not a moment may be lost in performing extraction should it become 
necessary. At the same time everything required for the resuscitation 
of the asphyxiated child should be ready for instant use. It is most im¬ 
portant to remember that the completion of labor is materially facilitated 
by the arms retaining their normal crossed position over the thorax, as 
well as by sharp flexion of the head. This is best attained by avoiding 
traction as far as possible and by moderate downward pressure upon the 
fundus as soon as the breech begins to emerge through the vulva, which 
should be maintained by the nurse or an assistant, so that the obstetrician 
can keep his hands clean for any emergency. 

Owing to the fact that the breech forms a less efficient dilating wedge 
than the head, care should be taken to prevent premature rupture of the 
membranes and the escape of the amniotic fluid. For this reason, as 
well as to facilitate dilatation of the outlet, Yignes states that Con- 
velaire for many years has introduced a rubber balloon into the vagina 
as soon as the external os has dilated to five centimeters in diameter. 
By so doing he has reduced the foetal mortality by more than one-half, 
and the incidence of perineal tears by 60 per cent. I have had no ex¬ 
perience with the method. 

Generally speaking, the frank breech forms a better dilating wedge 
than the complete breech, inasmuch as it allows a closer application 
to the margins of the partially dilated os. On the other hand, if 
interference becomes necessary, the complete breech offers more satis¬ 
factory conditions for immediate delivery, as a foot can readily be 
brought down and used as a tractor, so that the question arises 
whether it might not be better in the former class of cases to make it 
a rule to bring down one or both feet prophylactically. Usually this is 
not advisable, unless some abnormality exists on the part of the mother 
or child which renders it probable that prompt delivery may be called 
for. In such cases as soon as the cervix is practically fully dilated, the 
membranes should be ruptured and both feet brought down into the 
vagina so that extraction can be promptly effected when necessary. 
The technic of this manipulation, as well as the rules for extraction, 
will be considered in Chapter XXI. 

LITERATURE 

Ahlfeld. Die Entstehung von Stirn- imd Gesichtslagen. Leipzig, 1873. 
Baudelocque. L’art des accouchements, 1789, t. ii, 36-40. 

Boer. Sieben Bucher liber natiirliche Geburtshiilfe. Wien, 1834, 96. 

Bretz. Geburt bei Stirnlage mit querverlaufender Stirnnaht. Zentralbl. f. Gyn., 

1922, 2065-2067. 

Capon. Intracranial traumata in the New-born. Jour. Obst. and Gyn. Brit. Emp., 

1922, xxix, 572-590. 

Deleurye. Traite des accouchements, etc. Paris, 1770. 

Duncan. On the Production of Presentation of the Face. Mechanism of Natural 

and Morbid Parturition. Edinburgh, 1875, 218-231. 


LITERATURE 


325 


Fieux. Une observation de presentation primitive de la face. Comptes rendus 
de la soc. d’obst., de gyn. et peed., 1900, ii, 225-231. 

Fritscii. Klinik der geburtshiilfiichen Operationen. Ilalle, 1894, 142. 

Gessner. Zur Aetiologie der Gesichtslagen. Zeitschr. f. Geb. u. Gyn., 1897, 
xxxvii, 302. 

Hecker. Ueber die Schadelform bei Gesichtslagen. Berlin, 1869. 

Hodge. The Principles and Practice of Obstetrics. Philadelphia, 1866, 331. 

Holland. Cranial Stress in the Foetus During Labor, etc. Jour. Obst. and Gyn. 
Brit. Emp., 1922, xxix. 

Jellinghaus. Ueber fotale Schadelformen, etc. Archiv f. Gyn., 1896, li, 33-48. 

Kautsky. Eine neue Methode zur Sicherstellung von Zwllingsschwangerschaften, 
Beckenend- und Querlagen. Zentralbl. f. Gyn., 1921, 777-780. 

Lachapelle. Pratique des accouchements, 1821, t. i, 382. 

Markoe. Observations and Statistics on 60,000 Labors. Bull. Lying-in Hospital, 
New York, Dec., 1909. 

Morse. Pubiotomy in Posterior Face Presentations. Surg. Gyn. and Obst., 1912. 

Bilateral Congenital Caput Obstipum. Surg. Gyn. and Obst., 1915, xx. 74-77. 

Petitjean. Etude statistique concernant le cas de presentation de la face ayant 
lieu a la clinique Baudelocque. These de Paris, 1904. 

Pinard. Traite du palper abdominal, 2me ed., Paris, 1889, 32-50. 

Reed. Persistent Mento-posterior Positions. Am. Jour. Obst., 1905, li, 615-635. 

Ribemont-Dessaignes. Precis d’obstetrique, 1894, 425. 

Schatz. Die Umwandlung von Gesichtslagen zu Hinterhauptslagen durch allein- 
igen ausseren Handgritf. Archiv f. Gyn., 1873, v, 306-331. 

Ueber den Schwerpunkt der Frucht. Zentralbl. f. Gyn., 1900, xxiv, 1033-1036. 

Sellheim. Die Geburt des Menschens. Deutsche Frauenheilkunde, Bd. I, 1913. 

Die Physiologie der Geburt. Doederlein’s Handbuch der Geb., 1915, Bd. 1, 331- 
444. 

Spiegelberg-Wiener. Lehrbuch der Geburtshiilfe, II. Aufl., 1891, 172. 

Thorn. Zur manuellen Umwandlung der Gesichtslagen in Hinterhauptslagen. 
Zeitschr. f. Geb. u. Gyn., 1886, xiii, 186-220. 

Die Stellung der manuellen Umwandlung in der Therapie der Gesichts- und 
Stirnlagen. Yolkmann’s Sammlung klin. Vortrage, 1902, Nr. 339 

Vignes. Presentation du siege. Le Progres Medical, 1919, 378-379. 

Wallich. De la symphyseotomie dans les presentations persistantes du front. 
Comptes rendus de la soc. d ’obst., de gyn. et de peed., 1902, iv, 18-34. 

Weiss. Zur Behandlung der Gesichts- und Stirnlagen. Yolkmann’s Sammlung 
klin. Vortrage, N. F., Nr. 74. 

Winckel. Zur Lehre von den Gesichtslagen. Klinische Beobachtungen zur 
Pathologie der Geburt. Rostock, 1869, 59-65. 

Zeller. Bemerkungen iiber einige Gegenstande aus der praktischen Entbindungs- 
kunst. Wien, 1797. 

Zimmermann. Zur Mechanismus bei Stirnlage. Zeitschr. f. Geb. u. Gyn., 1921, 
lxxxiii, 725-735. 

Zweifel. Lehrbuch der Geburtshiilfe, III. Aufl., 177. 




CHAPTER XIY 


PHYSIOLOGY AND MANAGEMENT OF THE THIRD STAGE OF LABOR 

Situation of the Placenta in ITtero.—The older authors believed that 
the placenta was usually implanted at or in the immediate neighborhood 
of the fundus. The researches of Schroeder, Pinard, Ahlfeld, Leopold, 



Fig. 297. —Diagram showing Relation 
of Placenta to Uterine Wall in 
Latter Part of Pregnancy. X Y - 


Holzapfel, and others, however, 
have shown that this is by 
no means the rule, but that the 
most common situation is on the 
anterior or posterior wall of 
the uterus, occasionally on its 
lateral wall, and only in ex- 



Fig, 298. —Diagram showing Relation 
of Placenta to Uterine Wall in 
Second Stage of Labor (modified 
from Schroeder). X Y- 


ceptional instances upon the fundus. Fig. 297, which represents a 
vertical section through the uterus at term, shows the usual mode of 
attachment. As a rule, the lower margin of the placenta lies well above 

326 









MECHANISM OF SEPARATION OF THE PLACENTA 327 

the internal os, because when it impinges upon or overlaps the latter 
we have to deal with a pathological condition—placenta previa. 

Mechanism of Separation of the Placenta.—Under normal conditions 
the placenta remains fixed to the uterine wall until after the birth of the 
child,, and becomes sepa¬ 
rated from it only during 
the third stage of labor. 


The uterine contractions 
bring about a slight de¬ 
crease in the area of 
placental attachment du¬ 
ring the second stage, 
and in its attempt at 
accommodation the pla¬ 
centa becomes thicker 
and its margins more 
rounded and prominent. 

It is pressed firmly 
against the uterine wall 
by the amniotic fluid, 
through which the intra¬ 
uterine pressure is trans¬ 
mitted; otherwise it is 
probable that premature 
separation would be the 
rule and not the excep¬ 
tion. 

As the child is being 
expelled from the uterus, 
its cavity becomes prog¬ 
ressively smaller to corre¬ 
spond to the decreasing 
bulk of its contents, so 
that when the birth is 
completed, the uterine 
cavity has become oblite¬ 
rated and the organ is 
represented by an almost 
solid mass of muscle, 
whose fundus lies several 
centimeters below the 
umbilicus. A vertical 
section through the uterus at this time (Fig. 299), shows that as 
the result of contraction and retraction its walls have become several 
centimeters thick and are closely applied to the placenta, which is still 
attached, but, owing to the diminution in its area ot attachment, has 
become approximately twice as thick as at the onset of labor. 

As a result of the great decrease in the superficies of the rest of 
the interior of the uterus, the foetal membranes and the decidua vera are 


Fig. 299. —Vertical Section through Uterus Re¬ 
moved by Supravaginal Hysterectomy following 
Cesarean Section. X (Note thickness of 
muscle walls, decrease in area of placental attach¬ 
ment, and increase in thickness of placenta.) 





328 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR 


obliged to accommodate themselves to the changed conditions, and, as 
they are not contractile, they are thrown into innumerable small festoons 



Fig. 300.— Section through Wall of Pregnant Uterus Outside of Placental Site. 

X 66. (For comparison with Fig. 302.) 

A —amnion and chorion laeve; B —fibrin layer; C —decidua vera; D —muscularis. Note 

abundance of muscle spaces in this layer. 


or folds, so that the layer increases from a fraction of a millimeter to 3 
or 4 millimeters in thickness. 

Figs. 300 and 301, which represent the lining membrane of the 



Fig. 301. —Section through Uterine Wall Outside of Placental Site During 
Third Stage, Showing Festooning of Membranes. X 25. 

Am., amnion; C.E., epithelium of chorion; Dec., decidua vera; Mus., muscularis. 



















MECHANISM OF SEPARATION OF THE PLACENTA 


329 




; A "kAM 

t., * . ? y+ 


' €' 

'■ySM*. 

.t ‘Jf < *' 

* 5 ^ 3 ® * * <* s 


f 


••? -*« * f . ^ * ■+*.'*& Jfj 1 


✓•r* 


■ CCi. ■'.%.■ .. 


/ ... " # 

- / */ <•/ 


V* 


- included 

[ between the iolds of the festooned amnion and chorion laeve. 

? As the uterus continues to contract and retract, its muscular walls 
become thicker and 

thicker, and the area 
of the placental at¬ 
tachment smaller and 
smaller, so that even¬ 
tually a period is 
reached when the 
comparatively com¬ 
pact placenta can no 
longer follow this 
. change, and is peeled 
off from the uterine 
i wall and lies free in 
the cavity, whence it 
is expelled into the 
! collapsed and flabby 
lower uterine seg- 
i ment by further con- 
i tractions. The sepa- 
\ ration takes place in 
' the spongy layer of 
I the decidua basalis, 
j so that a portion is 
I cast off with the 
placenta, while the 
balance remains at¬ 
tached to the muscu- 
laris (Fig. 303). 

The process of de¬ 
tachment is inaugu¬ 
rated bv lesions of 
*/ 

continuity in the 
decidua, and is ac¬ 
celerated by the ef¬ 
fusion of blood into 
the spaces thus 
formed. 

The amount of 

decidual tissue which is retained at the placental site is dependent 
upon the original thickness of the decidua basalis, and varies within 
wide limits, as is well shown by Figs. 304 and 305, which represent 
the conditions in two normal uteri, which were amputated at cesarean 
section just after the extrusion of the placenta. 

The membranes usually remain in situ until the separation of the 


Mus 



Dec 


ngj 

- . ' If.: 3*r«*Vsj 

Fig. 302. —Portion of Fig. 301 More Highly 
Magnified. X 66. 

Am., amnion; C.E., epithelium of chorion laeve; 
Dec., decidua vera, gland spaces; Mus., mus- 
cularis; V., vascular spaces in decidua. 














330 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR 

placenta is practically completed, and are then peeled oft from the 
uterine wall partly hy the further contraction and retraction of the 
muscularis, and partly by traction exerted by the separated placenta, 
which now lies in the flabby lower uterine segment or the upper portion 

of the vagina. At this time the body 
of the uterus has become converted into 
an almost solid mass of muscle, whose 
anterior and posterior walls each measure 
4 to 5 centimeters in thickness and lie 
in such close apposition that the uterine 
cavity is practically entirely obliterated. 

Reference to Fig. 302 makes it clear 
that the greater portion of the decidua 
vera has been included between the fes¬ 
tooned folds of the amnion and chorion 
laeve, and must be cast off when sepa¬ 
ration occurs. Consequently the portion 
which remains attached to the uterine 




Fig. 303.—Diagram Showing 
Separation of Placenta, 
and Approximate Amount 
of Decidua Basalis Cast 
Off with it, and Retained 
in Utero. X 3. 

A, placenta; B, C, decidua 
basalis; D, muscularis. 


Fig. 304.— Diagram of Placental Site 
Showing Retention of Minimal 
Amount of Decidua Basalis. 

A, decidua basalis, with blood spaces and 
glands; B, muscularis. 

wall is relatively thin, and, were it not 
for the great decrease in the size of the 
uterine cavity, it would represent only 
a fraction of the thickness noted during 
the last days of pregnancy. 

Mode of Extrusion of the Placenta.— 
As early as 1789 Baudelocque had de¬ 
scribed two ways in which the placenta 
could be extruded from the uterus. Thus, 
separation from the uterine wall could 
commence either at the center of the 
placenta or at a point in its circumfer¬ 
ence. “In the first case the middle 


of the placenta being pushed forward 
by an effusion of blood beneath it, the 
organ becomes inverted upon itself in 
such a manner that it presents by its foetal surface, which is covered 
by the membranes and vessels. . . . But when the placenta becomes de¬ 
tached below, particularly if the loosening begins at a point in the 
neighborhood of the internal os, the mechanism is entirely different, for 









MODE OF EXTRUSION OF THE PLACENTA 


331 









. 

* 


the afterbirth becomes rolled upon itself in the form of a cylinder, whose 
long axis corresponds to that of the uterus, in such a manner that it 
presents its detached maternal surface to the examining finger, and its 
exit is always preceded by a small amount of fluid blood.” 

These ideas seem to have excited 
but little interest until 1865, when 
Schultze advanced the opinion that 
the placenta was usually expelled 
by the first method described by 
Baudelecque. This belief remained 
practically undisputed until 1871, 
when Matthews Duncan contended 
that the second was the more fre¬ 
quent and therefore the normal 
mechanism. The active discussion 
aroused by this controversy, although 
it led to no final settlement of the 
question, had the effect of directing 
more earnest attention to the physi¬ 
ology of this stage of labor. 


XL * 

m 1 * 

j" ^ td. «• — * V.->v 



# Ay" ' ' - - 'V 

f ' y 




The two methods are now desig- 
nated by the names of Schultze and 
Duncan respectively. In the former 
separation begins first at the central 
portion of the placenta, between 
which and the uterine wall more or 
less blood is poured out, which 
gradually increases in amount until 
a retroplacental hematoma of con¬ 
siderable size is formed, which even¬ 
tually brings about the complete 
separation of the organ from its site 
of attachment, while the membranes 
still remain adherent. The placenta 
then presents at the internal os by 
its foetal surface and, passing 
through the opening in the mem¬ 
branes, drags them after it; it is 
then expelled from the vulva, its 
foetal or amniotic surface first, and 
the now inverted membranes follow r - 
ing after. In this mechanism there 
is no escape of blood until after the 
extrusion of the placenta has. taken 
place (Figs. 306 and 307). 

In Duncan’s method, on the other hand, the placenta, after its separa¬ 
tion from the uterine wall, becomes folded upon itself and its lower mar¬ 
gin presents at the internal os. It then traverses the vagina and emerges 
from the vulva by one margin, the membranes being sometimes, but by 



Fig. 305. —Diagram of Placental 
Site showing Retention of 
Excessive amount of the 
Spongy Layer of the Decidua 
Basalis. 

A, decidua basalis; B, muscularis; 
B.V., blood vessel; Gld. glandular 
spaces. 








332 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR 


no means always, inverted. When expulsion occurs in this manner, there 
is slight but continuous hemorrhage from the birth of the child until 
the placenta is delivered (Fig. 308). 



Fig. 306.—Diagram illustrating Extrusion of Placenta by Schultze’s Mechanism. 

With respect to the relative frequency with which these two mechan¬ 
isms occur there has been much discussion. In this country and in Eng- 



Fig. 307.—Diagram illustrating Later Stage in the Extrusion of the Placenta by 

Schulzte’s Mechanism. 

land Duncan’s views are commonly accepted, while in Germany the opin¬ 
ions are still very conflicting. Holzapfel, in an excellent monograph, has 



























MODE OF EXTRUSION OF THE PLACENTA 


333 


given details and a full literature dealing with the status of the ques¬ 
tion up to 1899, and, concludes that the placenta nearly always presents 
at the internal os by Duncan’s, but leaves the uterus hy Schultze’s 
mechanism. 

Certainty in this respect was attained by means of the interest¬ 
ing experiments of Weibel, and Warnekros, who immediately after 
the birth of the child cut the cord, and, through its vessels, in¬ 
jected the placenta with a substance which would cast a shadow under 
the X-ray. Roentgenograms made immediately thereafter showed three 
things—first, that in two-thirds of the cases separation occurred with 
the first or second postpartum contraction; second, that the placenta 
always passed through the contraction ring by its margin, and that the 
formation of a retroplacental hematoma played very little part in bring- 



Fig. 308. —Diagram illustrating Extrusion of Placenta by Duncan’s Mechanism. 

ing about its separation; and third, that the mechanisms described by 
Duncan and Schultze developed only in the vagina and really applied 
only as the placenta emerged from the vaginal outlet. For this reason 
they contend that differentiation between the two methods is a matter 
of indifference, as the placenta always leaves the uterus in one way. 

While such a conclusion is doubtless correct, my experience is that the 
placenta usually escapes from the vulva by the Schultze mechanism, 
and similar views are held by Freeman and Polak. The former in 2,600 
consecutive labors observed in the Rotunda Hospital, Dublin, noted 
Schultze’s mechanism in 82.5 per cent, of the cases, and believes that 
more frequent occurrence of Duncan’s mechanism is attributable to 
kneading the uterus during the early portion of the third stage. In 
other words, the evidence available indicates that the placenta usually 
escapes from the uterus by the mechanism of Duncan, and emerges from 
the vulva by that of Schultze. 















334 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR 


Clinical Picture of the Third Stage of Labor. —Immediately following 
the birth of the child the remainder of the amniotic fluid escapes, after 
which there is usually a slight flow of blood. The uterus can now be felt 
as a firm, hard mass, the fundus lying well below the umbilicus. For a 
short time the patient experiences no pain, but after a few minutes uter¬ 
ine contractions begin again and recur at regular intervals, until the 
placenta becomes separated and is expelled into the lower uterine seg¬ 
ment. 

At some time, varying between five and thirty minutes after the 
birth of the child, palpation shows that the fundus of the uterus has 
risen up to or above the umbilicus, or three to seven centimeters above 
its original position, while simultaneously a slight prominence has ap¬ 
peared immediately above the symphysis pubis (Figs. 309 and 310), At 



Fig. 309.—Abdomen immediately after Birth of Child. 


the same time the portion of umbilical cord protruding from the vulva 
has increased by 10 or 12 centimeters in length. These changes indicate 
that the placenta has become detached and has been extruded from the 
uterine cavity proper into the lower uterine segment, or even into the 
upper part of the vagina. The rising of the fundus is due to the fact 
that the lower uterine segment, which immediately after the birth of the 
child had collapsed upon itself, is now distended by the placenta, and 
mechanically lifts the tightly contracted body of the uterus to a higher 
level. In rare cases the placenta is born almost immediately after the 
child, in about one quarter of the cases it is delivered spontaneously 
fifteen to thirty minutes later, while occasionally hours may pass before 
it appears at the vulva. The possibility of wide divergence in this re¬ 
spect can readily be appreciated when we remember that the action of 
the uterus ceases after the placenta has been extruded from its cavity, 
















MANAGEMENT OF THE THIRD STAGE OF LABOR 


337 


hand is then applied to the abdomen in such a manner that the thumb 
rests upon the anterior and the fingers upon the posterior surface of the 
uterus, and as soon as a contraction occurs, firm and steady pressure 
should be made downward in the axis of the superior strait. 

The introduction and routine employment of Crede’s method, which 
aimed at hastening the separation of the placenta and then expressing it 
from the uterine cavity, undoubtedly marked a most important advance, 
inasmuch as, by doing away with the necessity for traction upon the cord 
and the frequent manual removal of the placenta, it has saved the lives 
of thousands of women. With certain modifications it is now generally 
employed throughout the world. As a matter of history, Jellett has 
noted that the method, while usually ascribed to Crede, had been prac¬ 
ticed for many years previously at the Rotunda Hospital in Dublin, and 
appears to have originated with John Harvie in 1767. 

In opposition to the expression of the placenta immediately after the 
birth of the child, Dohrn, Ahlfeld, and others have stated that a greater 
amount of blood is lost during the third stage, and that there is a greater 
tendency to postpartum hemorrhage, due to imperfect separation, than 
when the extrusion of the placenta is left to nature, or when expression 
is resorted to only after an interval of several hours. But, while it is 
recognized as incontrovertible that too early a resort to Crede’s method 
is harmful, inasmuch as it defeats the very purpose for which it is em¬ 
ployed and interferes with the physiological separation of the placenta, 
the arguments adduced in favor of waiting so long a time appear to be 
neither satisfactory nor rational. It is difficult to see what advantages 
are to be gained by delaying expression after the placenta has once be¬ 
come detached from its original site and lies in the lower uterine seg¬ 
ment, more particularly as Ahlfeld claims that spontaneous delivery will 
occur only in less than 14 per cent, of the patients at the end of two hours. 
Furthermore, there are certainly very obvious objections to any un¬ 
necessary prolongation of the third stage of labor. For the patient 
such a delay means additional discomfort, while the busy physician can 
ill afford the expenditure of valuable time, unless he be convinced that 
by such personal sacrifice he can better insure the well-being of his 
patient. 

In normal cases, therefore, attempts at expression should not be made 
until the placenta has been spontaneously expelled into the lower uterine 
segment or upper portion of the vagina, as is indicated by the rising up 
of the fundus; but as soon as this has taken place there is no reason why 
the process should not be hastened. In my own clinic the following pro¬ 
cedure has been adopted with satisfactory results. As soon as the child 
is born the hand is laid upon the abdomen, and if the uterus be felt as a 
firm, hard, globular mass it is left absolutely alone. On the other hand, 
if it appears to be soft and flaccid, it is gently kneaded until firm con¬ 
tractions are induced. The condition of the uterus is then carefully 
watched by applying the hand to it at intervals of five minutes, but 
kneading it only when necessary. In the majority of cases, after a lapse 
of ten or fifteen minutes, it is noticed that the fundus rises spontaneously 
several centimeters above the position which it had just occupied, and at 




338 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR 


the same time remains firm and hard. This change indicates that the 
placenta has become separated from the uterine wall and is distending 
the lower uterine segment or the upper portion of the vagina. In doubt¬ 
ful cases important information may sometimes be obtained by holding 
the cord lightly between two fingers and making firm pressure upon the 
uterus with the other hand. If the placenta is still adherent, a distinct 
wave will be felt in the cord, which will be absent if separation has al¬ 
ready occurred. Attention was first directed to the significance of the 
rising of the fundus by Pinard, Schroeder, and Cohn, but its importance 
has not been generally recognized. The placenta is now expelled by 
grasping the uterus and making downward pressure in the axis of the 
superior strait, using the uterus merely as a piston to shove the placenta 
through the vagina. When the latter appears at the vulva it should be 
grasped by the hand and the membranes gently twisted into a cord, so 
as to prevent their being torn off from the margins of the placenta, after 
which they are slowly extracted. 

The modification here recommended, which we designate as “expres¬ 
sion from the vagina,” leaves the separation of the placenta from the 
uterine wall absolutely to nature, and simply expresses it after it has 
been spontaneously expelled from the uterine cavity, and should not be 
confounded with the original Crede method, whose object is to hasten the 
separation of the organ and to express it from the uterine cavity. In 
most cases the placenta can be expressed from the vagina within half an 
hour after the birth of the child; but if the fundus does not rise up 
spontaneously by the end of that period, it is my practice to attempt to 
hasten separation by resort to the typical Crede method of expression. 

Frequently small portions of the membranes may be left behind 
in utero or in the vagina. If the ends be outside the vulva, they should 
be seized with an artery clamp and the remnants delivered by gentle 
traction; but otherwise it is advisable to leave them alone and to allow 
them to be cast off with the lochia, rather than to introduce the fingers 
into the vagina or uterus in the attempt to remove them. 

Immediately following the hirth of the placenta the uterus should be 
again palpated; normally it will be found firmly contracted and retracted, 
and (if it remains so) there is no danger of hemorrhage. But, on the 
other hand, if it shows any tendency toward relaxation, it should be 
kneaded until it contracts, and the hand kept constantly upon it, so that 
beginning relaxation may be detected and combated. There is usually no 
danger of relaxation and consequent hemorrhage, provided no signs of it 
appear during the first hour after the extrusion of the placenta. Ac¬ 
cordingly, the condition of the uterus should be carefully watched during 
that period by the physician or nurse. But, even when this duty is dele¬ 
gated to the latter, the physician should remain at the house of the pa¬ 
tient for one hour, so as to be on hand in case an emergency should arise. 
In normal cases, there is no objection to administering one cubic centi¬ 
meter of pituitary extract hypodermatically, as a prophylactic measure, 
immediately after the extrusion of the placenta. While it is not neces¬ 
sary, the prompt and vigorous contractions which it induces add some¬ 
what to the peace of mind of the physician and can do no harm. On 


LITERATURE 


330 


the other hand, the drug should not be employed so long as the placenta 
remains in situ, for fear that it may give rise to an hour-glass con¬ 
traction of the uterus and thereby unnecessarily prolong the third stage 
of labor. 

Occasionally, the amount of blood lost immediately following the 
birth of the child may be so great as to render imperative the prompt 
delivery of the placenta, and under such circumstances Crede’s method 
of expression should be employed at once. Under all other conditions, 
however, we should watch for the rising up of the fundus before resorting 
to any form of expression. 

As soon as the placenta and membranes are born they should be care¬ 
fully inspected for the purpose of ascertaining whether they have been 
expelled entire, or whether portions have been left behind in the uterus. 
If they are perfectly intact, all is well; but if the maternal surface of the 
placenta shows defects which are not due to mere tears of its substance, 
but which appear to indicate that a considerable part has been left be¬ 
hind, the hand should be carefully redisinfected, a sterile rubber glove 
put on, and the retained portion removed manually, since if allowed to 
remain in the uterus it nearly always gives rise to hemorrhage. 

In rare cases spontaneous separation does not occur, and it may be 
found impossible at the end of half an hour to expel the placenta by 
means of Crede’s method. In such circumstances, unless the condition of 
the patient be serious, or there be free hemorrhage, the obstetrician 
should wait patiently and repeat his attempts at expression at intervals, 
and should not despair of eventual success until two hours have elapsed. 
In case of failure, it is probable that abnormal adhesions exist between 
the placenta and the uterine wall, but, in any case, manual removal of 
the organ must never be undertaken unless this course seems absolutely 
necessary, as it is a more serious procedure than most obstetrical opera¬ 
tions. In the former instance, the hand is introduced between the 
placenta and the uterine wall, and comes in direct contact with the 
freshly thrombosed vessels at the placental site, which afford a most 
excellent culture medium for bacteria: whereas in the latter the hands 
or instruments are introduced into the amniotic cavity, so that whatever 
microorganisms may have been carried up by them are likely to be cast 
off with the afterbirth. 

For particulars concerning the control of excessive hemorrhage or the 
technic of manual removal of the placenta, the reader is referred to the 
sections on hemorrhage and on obstetrical operations, respectively. 

LITERATURE 

Ahlfeld. Abwartende Methode oder Crede’scher Handgriff? Leipzig, 1888. 

Ueber die ersten Vorgange bei der physiologischen Ldsung der Placenta. 

Zeitschr. f. Geb. u. Gyn., 1895, xxxiii, 418-442. 

Weitere Untersuchimgen iiber die physiolog. Vorgange der Nachgebnrtspenode. 

Zeitschr. f. Geb. u. Gyn., 1897, xxxvi, 443-466. 

Die Blutung bei der Geburt, etc. Zeitschr. f. Geb. u. Gyn., 1904, li, 341-364. 

BvudelocQUE. Be la delivrance naturelle. L’art des accouchements, 1789, t. i, 

413-415. 





340 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR 


Cohn. Zur Physiologie und Diiitetik der Nacligeburtsperiode. Zeitsclir. f. Gel), u. 
Gyn., 1886, xii, 381-417. 

Crede. Ueber die zweckmassigste Methode der Entfernung der Nachgeburt. Mo- 
natsschr. f. Geburtskunde, 1861, xvii, 274-292. 

Ueber die zweckmassigste Methode der Entfernung der Nachgeburt. Archiv f. 
Gyn., 1881, xvii, 260-280. 

Dohrn. Zur Behandlung der Nachgeburtsperiode. Deutsche med. Wochenschr., 
1880, vi, 545-547, Nr. 41. 

Die Behandlung des Nachgeburtszeitraumes. Jena, 1898. 

Duncan. The Expulsion of the Placenta. (Read to the Edinburgh Obstetrical 
Society, March 22, 1871.) Mechanism of Natural and Morbid Parturition. 
Edinburgh, 1875, 246-256. 

Freeman. The Third Stage of Labor. Am. Jour, of Obst., 1914, lxix, 302-309. 
Harvie. Practical Directions Showing a Method of Preserving the Perinaeum in 
Child-birth and Delivering the Placenta without Violence. London, 1767. 
Holzapfel. Ueber die Losung und Ausstossung der Nachgeburt. Beitrage zur 
Geb. u. Gyn., 1899, ii, 413-481. 

Jellett. The Dublin Method of Effecting the Delivery of the Placenta. Dublin 
Jour. Med. Science, June, 1900, cix, 412-422. 

Leopold. Die Diagnose des Plaeentarsitzes in der Schwangerschaft und wahrend 
der Geburt. Arbeiten aus der koniglichen Frauenklinik in Dresden, 1895, ii, 
151-166. 

Pinard. Du palper pendant la delivrance normale. Traite du palper abdominal, 
2me ed., Paris, 1884, 241-253. 

Pinard et Varnier. Etudes d’anatomie obstetricale normale et pathologique. 
Paris, 1892. 

Polak. A Study of the Management of the Placental Stage of Labor. Surg. 
Gyn. and Obst., 1915, xxi, 590-593. 

Schroeder. Beitrage zur Physiologie der Austreibungs- und Nachgeburtsperiode. 
Zeitschr. f. Geb. u. Gyn., 1885, xi, 421. 

Schroeder und Stratz. Zur Physiologie der Austreibungs- und Nachgeburts¬ 
periode. Der schwangere und kreissende Uterus. Berlin, 1886, 75-112. 
Sciiultze. Wandtafeln zur Schwangerschaft und Geburtskunde. Leipzig, 1865. 
Ueber den Mechanismus der spontanen Ausscheidung der Nachgeburt, etc. 
Deutsche med. Wochenschr., 1880, vi, 252. 

Warnekros. Die Nachgeburtsperiode im Rontgenbilde. Archiv f. Gyn., 1918, 
cix, 266-283. 

Weibel. Studien liber die Nachgeburtsperiode auf Grund rontgcnographischer 
Darstellung. Archiv f. Gyn., 1919, cxi, 413-507. 

Williams, J. W. A Histological Study of 50 Uteri Removed at Caesarean Section. 
Bull. Johns Hopkins Hospital. 1917, xxviii, 335-343. 

Tolerance of Freshly Delivered Women to Excessive Loss of Blood. Am. Jour. 
Johns Hopkins Hospital Bulletin, 1917, xxviii, 335-343. 





CHAPTER XV 


CONDUCT OF NORMAL LABOR 

The services of the obstetrician should be engaged as long as possible 
before the expected date of confinement, in order that the patient may 
have the advantages of medical supervision during at least the second 
half of pregnancy. 

The importance of a careful preliminary examination, not later than 
four to six weeks before term, has already been insisted upon. This 
should be carried out with the patient upon a suitable examining table 
or a firm bed, with sufficient clothing removed to give free access to all 
parts of the body. After making a thorough general physical examina¬ 
tion, the obstetrician should take careful measurements of the pelvis, de¬ 
termine the presentation and position of the child, and acquaint himself 
with any abnormality which may exist in the generative tract. At the 
time of this visit, if the patient is to be delivered at home, it is well 
to give her a list of such articles as may be needed at the time of labor 
and during the puerperium, and which she is expected to supply. The 
physician should also communicate with the nurse in order to make 
sure that she understands the preparations which fall to her share. 
Experience has taught me that the only way by which mistakes can be 
avoided is to use printed cards containing definite and concise in¬ 
structions for both the patient and nurse. 

Preparations for Labor on the Part of the Patient and Nurse.—If 
the patient is to be delivered at home, the room, to be used for the 
confinement, should be inspected in advance and suggestions made as 
to its arrangement. The obstetrician should also inquire as to the num¬ 
ber of wash-basins which are available; for with the increasing per¬ 
fection of plumbing the portable wash-basin is replaced by the permanent 
washstands, so that in the homes of the well-to-do it is sometimes difficult 
to find a sufficient number for disinfecting the hands and cleansing the 
patient. Four basins will be needed: three for the use of the physician 
and one for the nurse; and if so many are not already in the house, a 
sufficient number, made of plain agate-ware and measuring 10 inches 
across the top, should be procured. 

The patient should also be instructed to provide herself with a bed- 
pan, a 2-quart fountain syringe for rectal enemata, 15 yards of non- 
sterilized gauze and 2 pounds each of cotton batting and absorbent cotton 
for making bed-pads, or 6 prepared sanitary bed-pads and 2 pieces of 
rubber sheeting, one 1 X 2 yards and the other 1 X 1V 2 ? for protecting 
the bed and bed covering. In addition to the above mentioned requisites 
the following articles should also be obtained from the drug store at 

341 






342 


CONDUCT OF NORMAL LABOR 


least one month before the expected date of confinement, so that they 
may be in readiness in case labor should occur unexpectedly: 


100 cubic centimeters Squibb ’s chloro¬ 
form, 

4 ounces boric acid, 

2-ounce tube of green soap, 

100 bichlorid tablets, 


1-ounce tube of vaseline, 

8 ounces alcohol, 

4 drams ergotol, 

1 nail-brush, 

2 pounds absorbent cotton. 


If one has a large obstetrical practice it is advisable to have some 
reputable druggist arrange and keep in stock a box containing the above- 
mentioned articles, so that the patient can be told simply to buy an 
obstetrical outfit. 

Below is given the card which I prepared, while engaged in private 
practice, for the nurse, containing directions for the preparations before 
and at the time of labor, as well as for the care of the mother and baby 
afterward: 


DIRECTIONS FOR OBSTETRICAL NURSE 

PREPARATIONS BEFORE LABOR 

(a) If the patient is to be delivered at home, see that she has pro¬ 
cured a “Confinement Outfit,” and the other articles called for in “Direc¬ 
tions for Patients,” which include everything you or I shall need except 
baby clothes. 

(b) Prepare a sufficient number of sterile vulval pads. 

(c) A week before the expected date of confinement prepare seven 
packages, three containing six towels or diapers each; one containing 
leggings, two containing gauze sponges, and another containing cotton 
pledgets. Carefully sterilize and label them. 

AT TIME OF LABOR 

(a) If the patient is to be delivered in the hospital, take her there 
as soon as she is having regular pains at ten minute intervals. If, 
however, she is to be delivered at home, and pains begin between 8 a.m. 
and 11 p.m., notify me as soon as possible, so that I may know that 
labor has commenced and make my plans accordingly. But if labor 
begins after bed-time, do not notify me until morning, unless you think 
it necessary for me to see the patient at once. 

( b ) At the commencement of labor prepare two large pitchers of 
boiled water. Keep one hot and allow the other to cool, covering each 
with a clean towel. 

(c) When labor has definitely set in, give the patient a warm bath 
and a soap-suds enema. 

(d) Make up the bed on the left side. 

( e) Procure a piece of oilcloth or an old rug to protect the floor. 

(/) Don’t give vaginal douches of any kind. 





PREPARATIONS FOR LABOR 


343 


(g) Don't examine patient vaginally under any circumstances. 

( h) To prepare the patient for vaginal examination place her upon a 
douche pan, and cut the pubic hairs. Then wash the genitalia thoroughly 
from above downward (toward the anus) with soap and warm water, 
using cotton pledgets instead of a wash cloth. Finally, bathe the vulva 
with a 1-1,000 bichlorid solution, and then cover it with a towel soaked 
in the same solution. 

(i) Before a vaginal examination, drape the patient with a clean 
sheet in order to minimize exposure, and when the birth of the child 
appears imminent, roll the nightgown up above the patient’s hips and 
pin it in position, then put on the obstetrical leggings. 

AFTER LABOR 

(a) As soon as labor is over, cleanse the genitalia with cotton pled¬ 
gets and water, and then bathe with bichlorid solution, after which apply 
a sterile vulval pad and place the patient upon a sterilized bed-pad. 

( b ) Don’t use an abdominal binder, unless especially directed to 
do so. 

(c) Change vulval pads as often as necessary, washing the genitalia 
each time with a 1-4,000 bichlorid solution. 

( d) Take temperature and pulse four times a day (8, 12, 4, and 8), 
unless otherwise directed, and record upon chart. 

(e) Don’t catheterize unless the bladder is distended, and not until 
after the patient has failed to urinate in a sitting position. 

(/) Give 1 oz. of castor oil on the third morning after labor, and 
repeat in four hours if not effectual. 

(g) Bathe nipples with saturated boracic solution before and after 
each nursing. 

(h) Watch carefully for cracked nipples, and report them to me at 
once. 

( i ) Diet: First twenty-four hours, milk, soup, tea, coffee or cocoa 
and buttered or soft toast. Second and third days, as above, with the 
addition of boiled or poached eggs, raw or stewed oysters, chicken breast, 
and wine jelly. Fourth and fifth days, as above, with the addition of 
sweetbreads, steak, chops, potatoes, rice, and fruit. Then gradually 
return to ordinary plain diet. 

CARE OF CHILD 

(a) Leave the baby alone until the mother is cared for, wrapping it 
in a woolen cloth and putting it in a safe place. (Not upon the mother’s 
bed or upon chairs.) 

(&) Wash the eyes with a boracic acid solution, unless otherwise di¬ 
rected. 

( c ) Rub the child thoroughly with sweet oil or albolene, and then 
give it a lap bath with castile soap and warm water. 

(d) Dress the cord with boric acid powder and sterile cotton, or an 

alcohol dressing.. 




344 


CONDUCT OF NORMAL LABOR 


( e) Wash the child daily in your lap, but do not give a full bath 
until the cord comes off. 

(/) Feeding: Until the milk appears, nurse three times a day, and 
don’t give any other food unless directed. After the milk appears, let 
the child suckle, except after its bath, every four hours by the clock, 
from 6 or 7 a. m. to 10 or 11 p. m. Time one feeding so that it will 
come directly after the bath, after which the child may be allowed to sleep 
as long as it will. 

Feed only once, or preferably not at all, between bedtime and 6 or 
7 A. M. 

As soon as the milk appears, write out a schedule for nursing and 
adhere to it, awakening the child at each feeding time if necessary. 

( g) Weigh the child twice a week and record the result. 

Preparations on the Part of the Physician.—When the physician has 
promised to attend an obstetrical patient he should hold himself in readi¬ 
ness to respond promptly at any hour within two weeks of the expected 
date of confinement, and should instruct the patient as to the best method 
of communicating with him without delay. If he is obliged to leave town 
about that time, he should notify the patient and arrange for a competent 
substitute to take his place if necessary. He should also remember that 
the proper care of such cases requires a great deal of time, and frequently 
no small sacrifice of personal convenience, and if he is not willing to place 
himself at the disposal of his patients, as far as may be necessary, he 
should refuse to attend them. Undue haste is one of the most frequent 
causes of unsatisfactory results in this branch of medicine. 

The physician in private practice should provide himself with an 
obstetrical kit, which should be neatly packed in an appropriate box 
or valise and be kept ready for immediate use. It should contain not 
only the instruments which he may need, but also the various drugs 
required for hand disinfection, anesthesia, and the usual emergencies, 
as well as a supply of sterile towels and dressings, in case the patient 
has failed to provide herself with such materials, and for emergency 
cases. The obstetrical valise should contain a pelvimeter, nail-clippers 
and a nail-cleaner, chloroform, alcohol, bichlorid tablets, green soap, and 
nail-brush, sterile vaseline, ergotol or fluid extract of ergot, pituitrin, 
tablets of sodium chlorid for preparing normal salt solution, and a 
hypodermic syringe with the usual tablets. There should also be a 
chloroform inhaler, a suit of white clothes, and several sterilized roller 
bandages for packing the uterus. Glass tubes containing sterile 
catheters, catgut and silkworm-gut sutures, and bobbin for trying the 
cord are also needed, as well as a legholder, and a Kelly perineal pad 
for operative cases. 

The following instruments for repairing perineal and cervical lacera¬ 
tions should be ready for immediate use in a sterilized package: A pair 
of scissors, a needle-holder, four artery clamps, dissecting forceps, long 
dressing forceps, bullet forceps, a Simon speculum, and also an as¬ 
sortment of needles. The valise should also contain a tin box, 402 X 
13 X 10 centimeters, provided with a lid and wooden handles. In this 
the various instruments can be packed when not in use, and at opera- 


CONDUCT OF THE FIRST STAGE OF LABOR 


345 


tions it serves as a boiler and as a receptacle for them after sterilization. 
A Tarnier axis-traction, or an ordinary Simpson forceps, should be 
carried, according as the physician has become accustomed to the one or 
other instrument, as well as a 3-quart fountain syringe with a glass 
nozzle for intra-uterine, and a hollow needle for subcutaneous injections 
of salt solution. The latter should be sterilized in advance and wrapped 
in a sterile towel, so as to be ready for immediate use. 

This list does not include the instruments required for the destructive 
operations, as they are not usually carried by the general practitioner. 



Fig. 312‘ —Obstetrical Bag. 


Everything mentioned in the above list may be packed into a box 
21 X 8 V 2 X 8 inches, or into a satchel measuring 20 X 10 inches at its 
base. 

Conduct of the First Stage of Labor.—As soon as the nature and se¬ 
verity of the pains indicate that labor has set in, the patient should 
receive a full bath and a rectal enema. When the physician arrives he 
should make a careful external examination, map out the presentation 
and position of the child, and listen to the fcetal heart. II the pelvis has 
already been found to be normal, and the vertex is firmly engaged, there 
is no necessity for making a vaginal examination, provided that the heart 
sounds are in good condition. Information concerning the degiee of 
dilatation of the cervix can be obtained by rectal examination, as well 
as by the extent to which the head has descended into the pelvis, as 
shown by abdominal and perineal palpation. Again, the rupture of the 
membranes and the onset of bearing-down pains usually indicate the 
beginning of the second stage. If examination shows that labor is not 























































340 


CONDUCT OF NORMAL LABOR 


well advanced, there is no necessity for the physician to remain with 
the patient, and he may leave to return again in a few hours. He should 
not, however, leave the house if the external os is fully dilated in a 
primiparous woman, or half dilated in a multipara, as in the latter the 
first stage is frequently very short, and the second occasionally terminates 
with a few expulsive pains. 

In general, if no abnormality is suspected, and the physician is well 
trained in the technic of abdominal palpation and rectal examination, 
vaginal examinations are unnecessary unless labor is unduly prolonged. 
They should be avoided for two reasons: to minimize the possibility 
of infection and to save the feelings of the patient as far as possible. 

Procedure in Hand Disinfection .—It is now generally admitted 
that it is impossible to render one’s hands absolutely sterile, no matter 
what method of disinfection may be employed. Even after the most 
rigorous directions have been scrupulously followed, there still remains 
a not inconsiderable danger of infection. 

With the view of still further minimizing these risks, the use of rub¬ 
ber gloves has been introduced. These can be rendered absolutely sterile 
by boiling, and, when drawn over the carefully disinfected hands, afford 
the greatest safety possible. Since, however, they are liable to tear oc¬ 
casionally, the necessity for disinfecting the hands before putting them 
on is apparent. But their employment, even in conjunction with all our 
other precautions, does not entirely do away with the possibility of intro¬ 
ducing pyogenic bacteria into the genital tract, since I have shown that 
they may be carried up from the vaginal outlet by the sterile gloved 
finger. In 1898 I demonstrated that pathogenic organisms are present 
upon the inner surfaces of the labia and the margins of the hymen in at 
least 60 per cent, of pregnant women, and that the mere introduction of 
a sterile glass speculum 2 centimeters in diameter, which is no larger 
than the two fingers employed for examination, carries microorganisms 
into the vagina in one-half of such cases. Moreover, inasmuch as the 
delicate structure of the parts renders their thorough disinfection out of 
the question, and as the examining fingers necessarily come in contact 
with them, it must be admitted that vaginal examinations during labor 
can never be entirely devoid of danger, and they should therefore be 
avoided so far as is consistent with the welfare of the patient. While 
these considerations should not deter us from making as many examina¬ 
tions as may be necessary in abnormal cases, it should always be borne in 
mind that the best results are obtained by the least possible employment 
of the vaginal touch, and the widest possible utilization of other methods 
of examination. 

If the hands of the physician have recently come in contact with in¬ 
fectious material at operation or autopsy, labor should be conducted by 
external manipulations alone, vaginal examinations being made only in 
the presence of some abnormality, and then only by the gloved hand. 

In all cases the hands should be disinfected as carefully as for a 
major surgical operation. Probably the best method for this purpose 
was introduced by Dr. Halsted, and described by Dr. Kelly in 1891, 
and consists of the following steps: 


CONDUCT OF THE SECOND STAGE OF LABOR 


355 


Generally speaking, the causes of rupture are fourfold: disproportion 
between the head and the vulva, too rapid expulsion, abnormalities in the 
mechanism of labor, or a narrow pubic arch. Where the head is unusu¬ 
ally large or the vulva excessively small, the mechanical conditions are 
such that birth cannot take place without a certain amount of laceration. 
In not a few cases the tearing is due not so much to absolute dispropor¬ 
tion between the head and the vulva as to the lack of elasticity of the 
perineum, which is particularly marked in elderly primiparae. Too 
. rapid expulsion, however, is a much more frequent cause of rupture, and 
when the head is suddenly and forcibly extruded through the imperfectly 
distended vulva its mode of production is manifest. 

Various abnormalities in the mechanism of labor favor rupture of 
the perineum. The most frequent of these is imperfect extension of the 
head, so that the vulva is distended by the occipito-frontal, instead of 
the suboccipitobregmatic or suboccipitofrontal circumference. In a cer¬ 
tain number of cases the presenting part may be directed too far back¬ 
ward—in other words, extension does not occur—and under the influence 
of the uterine contractions the presenting part is forced directly down¬ 
ward upon the perineal body, instead of being guided upward and for¬ 
ward toward the vulval opening. A similar condition is observed in 
women having funnel-shaped pelves, in which the pubic arch is long 
and narrow, whereby the head is prevented from engaging directly under 
the symphysis pubis. Again, in rare instances, an abnormal inclination 
of the pelvis, by causing the vulval opening to look more upward than 
usual, may bring about a similar condition. In considering the mechan¬ 
ism of labor, we directed attention to the factors which predispose to 
perineal rupture, when the head is delivered in persistent occipitopos- 
terior positions, or when the child presents by the brow, face, or breech. 

Giffard, in 1733, was the first to direct attention to the advisability 
of attempting to prevent perineal tears, and very precise directions were 
given by John Harvie in 1767. Numerous devices have since been 
suggested having the same object in view, but their very multiplicity 
argues that they are not uniformly satisfactory. In most of the older 
methods pressure was applied directly to the perineum, or various ah 
tempts were made to relieve the tension to which it was subjected, so 
that the physician was said to support the perineum. An excellent 
resume of the early literature upon the subject will be found in Goodell’s 
scholarly article, published in 1871. 

In the method which has stood me in best stead, no attempt is made 
to support the perineum by pressure, but the obstetrician simply endeav¬ 
ors to favor extension of the head and prevent it from being suddenly 
extruded during the acme of a pain. For this purpose, when the vertex 
distends the vulva widely, it should be seized between the thumb and 
three fingers of one hand, and forcible pressure made against it during 
each pain, in such a manner as to bring the occiput, and later the nape 
of the neck, directly in contact with the inferior margin of the symphysis, 
and thus increase extension. Accordingly, as soon as the head appears 
at the vulva, the physician should be ready to restrain its progress. He 
should hold his hand in such a manner as to be able to bring it immedi- 







356 


CONDUCT OF NORMAL LABOR 


ately into action, for in many instances the resistance of the vulva is 
unexpectedly overcome, and a single pain may be sufficient to push the 
head suddenly through it with a resulting perineal tear. After the head 
is so far born that the vulva is distended by the parietal bosses, it may 
be advisable to attempt to express it by Ritgen’s method in an interval 
between the pains. For this purpose, the patient having been instructed 
to open her mouth and not to attempt to bear down, the anesthesia is 
deepened. At the same time two fingers are applied just behind the anus, 
and forward and upward pressure is made upon the brow through the 


IPH..*" —'—:..- --— -?-;-J- ■ j 



Fig. 317. —Method of Holding back Head to Protect Perineum. 


perineum. I, however, only employ the method when spontaneous 
expulsion is delayed. 

fhe student is warned from attempting to protect the perineum by 
any method which aims at stripping it back over the presenting part, 
as such a procedure is useless, even if carried out successfully. The 
same may be said of the introduction of the finger into the anus, for 
the purpose of drawing the perineum up over the head, as suggested bv 
Dr. Goodell. In fact, all such procedures are not only of questionable 
utility, so far as the protection of the perineum is concerned, but are 
dangerous in that they contaminate the hand and throw it out of func¬ 
tion in case an emergency should arise which calls for its prompt in¬ 
troduction into the genital tract. 

was customary to introduce one or two fingers into the 



















CONDUCT OF THE SECOND STAGE OF LABOR 


357 

vagina as soon as the head reached the pelvic floor, so that it might not 
surprise the obstetrician by a sudden advance. Such a practice is 
extremely reprehensible, as it increases the possibility of contamination 
and infection. 

Many authorities, when rupture of the perineum seems imminent, ad¬ 
vise the performance of episiotomy. In this operation a strong pair of 
scissors is introduced between the head and the perineum, and an 
oblique incision made downward and backward on one or both sides 
between the anus and the tuber ischii. The operation is practiced in the 
belief that the vulval opening, if sufficiently enlarged by the incision, 
will not tear farther, or that in any case the laceration will occur in 
the continuation of the incisions, whose clean-cut edges will heal more 
readily than the irregular spontaneous tears. Personally, I see no ad¬ 
vantage in the procedure, as my experience is that ordinary perineal tears 
will heal almost uniformly if properly sutured and cared for. 

In an article entitled “Shall we Cut and Reconstruct the Perineum 
in every Primipara” ?, Pomeroy, in 1918, advocated making a midline 
incision as soon as the perineum begins to bulge, with the idea that its 
accurate repair immediately after delivery would prevent the develop¬ 
ment of relaxation of the pelvic floor in the future. While this may 
be so, it would appear to be an inadvisable routine procedure for two 
reasons: first, that it converts every labor into an operative one, and 
second, that if ideally successful its reoetition would be logically called 
for at each subsequent delivery. 

Coils of Corel about the Neele .—Immediately after the birth of the 
head, the finger should be passed to the neck of the child in order to 
ascertain whether it is encircled by one or more coils of the umbilical 
cord. This complication occurs in about every fourth case, and ordi¬ 
narily does no harm, but occasionally the vessels are pressed upon so 
tightly that asphyxiation results. If such a coil be felt, it should be 
drawn down between the fingers, and, if loose enough, slipped over the 
child’s head; but if it be too tightly applied to permit of this procedure, 
and the head appears congested and suffused, the cord should be seized 
and cut between two artery clamps, and the child immediately extracted. 

Delivery of the Shoulders .—In the majority of cases the shoulders 
appear at the vulva just after the occurrence of external rotation, and 
are born spontaneously. Occasionally, however, a delay occurs and im¬ 
mediate extraction may appear advisable. To accomplish this the occiput 
and chin should be seized by the two hands, and downward traction 
made until the anterior shoulder appears under the pubic arch; next, 
by an upward movement, the posterior shoulder should be delivered, after 
which the other shoulder will usually drop down from beneath the 
symphysis. 

The body almost always follows the shoulders without difficulty, but 
in case of prolonged delay its birth may be hastened by traction upon 
the head, but not by hooking the fingers in the axillae, since by the 
latter procedure the nerves of the arm may be injured and transient or 
permanent paralysis result. Indeed, even when the former method of ex¬ 
traction is employed, traction should be exerted only in the direction of 






358 


CONDUCT OF NORMAL LABOR 



the long axis of the child, for if it be made obliquely the neck will be 
bent upon the body, when excessive stretching of the brachial plexus on 
its convex side may occur, with subsequent paralysis. 

Tying the Cord .—Immediately after its birth the child usually makes 
an inspiratory movement and then begins to cry. In such circumstances 
it should be placed between the patient's legs in such a manner as to 
leave the cord lax, and thus avoid traction upon it. If, however, the child 
does not begin to breathe immediately, the cord should be seized and 
cut between two artery clamps, and efforts at resuscitation commenced 

at once. 

Normally, the cord should not be 
ligated until it has ceased to pul¬ 
sate. In securing it, a ligature of 
sterilized bobbin should be applied 2 
centimeters from the abdomen of the 
child and tightly tied; a second 


Fig. 318. —Traction to Bring about 
Descent of Anterior Shoulder. 

ligature is placed several centimeters 
above the first, and the cord cut between 
the two. Usually ligation of the maternal end 
merely serves to avoid soiling the bedclothes by blood 
escaping from it; but in single ovum twin pregnancies 
double ligation is essential, for there may be such extensive 
anastomoses in the placental circulation that the second child, while 
still in the uterus, may bleed to death from the maternal end of the 
cord of the first. 

The question as to the proper time for tying the cord has given rise 
to a great deal of discussion. Formerly it was the custom to ligate it 
immediately after the birth of the child; but Budin showed that 92 
cubic centimeters more blood escaped from the maternal end of the 
cord after early than after late ligation, thus indicating that that amount 
was lost to the foetus by early ligation. Schueking demonstrated the 
same fact by weighing the child just after birth and again after the 
cord had ceased to pulsate. Budin believed that this amount of blood 


was drawn into the circulatory system of the foetus by thoracic aspira¬ 
tion, while Schiicking held that it was driven into it as a result of 
the compression of the placenta by the contracting uterus. 






359 


CONDUCT OF THE SECOND STAGE OF LABOR 


I have always practiced late ligation of the cord and have seen no 
injurious effects following it, and therefore recommend its employment, 
unless some emergency arises which calls for earlier interference. 

After ligation of the cord, the child should be wrapped in a piece 
of flannel or blanket prepared for the purpose, and laid in a safe place 
until the placenta is born and the mother has been cleaned up and made 
comfortable. 



marked benefits derived from anes¬ 
thesia when operative procedures 
are to be undertaken, and, except 
for a few who still believe in fol¬ 
lowing literally the biblical in¬ 
junction—“in sorrow shalt thou 
bring forth”—all intelligent wo¬ 
men at present demand to be 
spared as far as possible from the 
suffering incident to the completion of normal labor. 

The most generally used anesthetics are ether and chloroform, and 
when obstetrical operations are to be performed it makes very little 
difference which is employed, as it is well-known that the dangers in¬ 
cident to chloroform are markedly reduced at the time of labor. It 
should, however, be remembered that this immunity is limited to the 
parturient woman, and does not exist during the puerperium, when 
chloroform is quite as dangerous as at other times. Exactly why this 
immunity should exist is a question which has not yet been definitely 


Fig. 319. —Delivery of Posterior 
Shoulder. 


Anesthesia .—We are indebted to Sir James Y. Simpson for the 
introduction of anesthesia into obstetrical practice. He employed ether 
for this purpose in the year 1847, 
and replaced it by chloroform after 
he had discovered the anesthetic 
properties of the latter drug. Chan- 
ning of Boston introduced the prac¬ 
tice into America. Although it at 
first encountered great opposition 
from physicians, clergymen and lay¬ 
men, every one now agrees as to the 








360 


CONDUCT OF NORMAL LABOR 


settled, but it is nevertheless a fact which has been established beyonc! 
peradventure. 

Generally speaking, chloroform is preferable in normal labor, for by 
its use obstetrical anesthesia can be rapidly and safely produced. I be¬ 
lieve that it is practically devoid of danger when properly administered, 
and should be used whenever there is time for its administration, unless 
the patient has conscientious objections to its employment. 

The choice of the time for its administration, however, is of great 
importance, nor should it he used before the latter part of the second 
stage, when the head becomes palpable through the perineum. A few 
drops of chloroform should then be poured upon the inhaler, and with 
the beginning of a pain the patient should be instructed to breathe in 
the fumes' vigorously; but as soon as the contraction has ceased the 
inhaler should be removed, to be used again when the patient makes a 
sign that she feels the first indication that another is beginning. This 
is known as obstetrical anesthesia or anesthesia a la reine, for the reason 
that Queen Victoria was the first crowned head to submit to its use, 
and is intended merely to diminish the sensation of pain and not to 
produce complete unconsciousness. When properly administered, the 
patient experiences marked relief after a few inhalations, but retains 
consciousness and is generally able to talk rationallv. When the disten- 
tion of the vulva is at its maximum, obstetrical anesthesia is not sufficient 
to abolish the pain, and it is my practice at that time to render the 
patient completely unconscious by increasing the dose of the drug. 

By this procedure the woman is saved an immense amount of avoid¬ 
able suffering, and at the same time the danger of perineal lacera¬ 
tion is diminished. For, if the pain is minimized, and done away with 
entirely at the critical moment, the patient will lie still instead of tossing 
in bed, and there will not be the same danger of the head being sud¬ 
denly expelled at the acme of a contraction, while the physician is 
employing his energies in persuading the patient to keep quiet, or may 
even be forcing her legs apart so that he may be able to protect the 
perineum. The amount of chloroform required for this purpose rarely 
exceeds 2 or 3 drams. 

The administration of chloroform should not be resorted to in the 
first stage, except in the presence of exceptional indications. Leaving 
out of consideration its possible influence upon the efficiency of the 
uterine contractions, it is only natural that as soon as the patient has 
experienced the soothing effects of the drug she is extremely loath to do 
without it, and, once having begun, the physician may find himself 
forced to continue its administration, unless he possesses more fortitude 
than is generally the case. 

Against the employment of anesthetics in labor, it has been urged 
that they diminish the force of the uterine contractions. This state¬ 
ment is partially correct, for when administered for any great length 
of time they undoubtedly lead to a shortening of the contractions and 
to a prolongation of the interval between them, as was demonstrated 
by the experiments of Donhoff and Hensen. On the other hand, when 
exhibited only at the proper time and in no excessive amount, this 




CONDUCT OF THE SECOND STAGE OF LABOR 


361 


objection does not hold good, and in many instances small doses even 
appear to stimulate the uterine contractions, and, by diminishing the 
sensation of pain, enable the patient to bring her abdominal muscles into 
full play, which she previously may have been unwilling to do, and thus 
hasten the completion of labor. 

Again, it has been taught that anesthesia predisposes to relaxation of 
the uterus after the expulsion of the placenta, and thus increases the 
danger of postpartum hemorrhage. So far as my own experience goes, 
such sequelae are not likely to occur, provided the drug has been properly 
administered. At the same time it must be admitted that its prolonged 
administration does tend toward uterine inertia, and is not without 
a deleterious influence upon the child. 

In exceptional cases chloroform, while diminishing the pain, appears 
to excite the patient. Under such conditions its use should be discon¬ 
tinued unless complete anesthesia is necessary. It should never be used 
in the first stage of prolonged labors in the hope of hastening the dilata¬ 
tion of the cervix, as this object is better attained by the proper 
administration of chloral or morphia. Ordinarily the patient is allowed 
to come from under the influence of the anesthetic as soon as the child 
is born, as its exhibition is not necessary in the third stage of labor, 
except when the placenta is to be removed manually, or an extensive 
perineal laceration is to be repaired. 

Nitrous Oxid Gas Analgesia .—Although gas has occasionally been 
employed for the induction of anesthesia in obstetrical operations, more 
particularly in cesarean section upon patients whose general condition 
contra-indicates the use of the usual anesthetic agents, it was not until 
1915 that Webster, Lynch and Davis directed especial attention to the 
feasibility of inducing obstetrical anesthesia by its means. 

These authors pointed out that by the aid of modern apparatus 
it is possible to induce the same type of analgesia with a mixture of 
nitrous oxid gas and oxygen, as with chloroform administered a la reine, 
and that if a few whiffs of gas are given with the onset of the contraction 
and are replaced by oxygen as it passes off, the patient soon loses all 
sensation of pain, but still retains consciousness. They likewise claim 
that this form of analgesia has the great advantage over that pro¬ 
duced by chloroform in that it stimulates rather than diminishes the 
frequency and intensity of the uterine contractions during the second 
stage, and thereby may actually shorten the duration of labor. Moreover, 
Lynch contends that its administration may be begun early in the 
first stage and be continued almost indefinitely without injury to the 
mother or child. 

Having extensively employed this form of anesthesia for years, I 
strongly advocate its use in normal labor in hospital practice, although 
full anesthesia must be induced as the head passes the vulva, which 
sometimes requires switching over to ether for a few minutes. Fuither- 
more, the administration of gas does not predispose to excessive post¬ 
partum bleeding, and apparently has no injurious effects upon either 

the mother or child. 

While Lvnch may be correct in stating that gas anesthesia may be 








3G2 


CONDUCT OF NORMAL LABOR 


safely continued for many hours, I feel that its use should he limited to 
the second stage* but, in view of the fact that it stimulates rathei than 
retards uterine activity, it may be commenced as soon as the cerv ix has 
become fully dilated, instead of waiting until the presenting part has 
reached the pelvic lloor, as with chloroform or ether. Furthermore, I 
believe tha't the method will necessarily be restricted to hospital use and 
to practice among the well-to-do; as the actual cost of the gas, the 
transportation of the more or less cumbrous apparatus, and the necessity 
of a trained assistant to manipulate it place it beyond the means of 
the ordinary patient in her own home with whom chloroform or ether 
will retain their pre-eminence. 

In my hospital service chloroform, or gas and oxygen is administered 
during the second stage in all normal labors, and if, in addition, 1/12 
grain of heroin be administered hypodermatically as soon as the cervix 
has dilated to 3 or 4 centimeters in diameter, and the patient be kept 
in a semi-darkened room, from which all unnecessary noise is excluded, 
the suffering is reduced to a bearable minimum, and most of the ad¬ 
vantages attending “twilight sleep” are obtained without its dis¬ 
advantages. In my experience, heroin is greatly superior to morphia 
in its analgesic action, and it possesses the additional advantage that 
it does not decrease the intensity of the uterine contractions and has 
no deleterious effects upon the child. 

8copolamin-m,orphin Anesthesia .—This method of combating the 
pain of labor was introduced in 1902 by Steinbiickel, who reported that 
the hypodermic injection of 0.0003 gram of scopolamin hydrobromate 
and 0.01 gram of morphia gave most satisfactory results and practically 
annulled the pains of labor, even permitting the application of forceps 
or the artificial dilatation of the cervix. 

In 1907 Gauss reported its administration in 1,000 cases in Kronig’s 
clinic in Freiburg, and stated that by a proper regulation of dosage 80 
per cent, of the patients would pass into a semiconscious state, which 
he designated as “Twilight Sleep.” In this condition the patient appears 
to appreciate pain at the time, but has no recollection of it later. For 
this purpose he administers 0.0003 gram of scopolamin and 0.01 of 
morphia hypodermatically, and repeats the scopolamin, but not the 
morphia, once or several times later if necessary. The indication for 
its repetition is not afforded by the lapse of any specified length of 
time, but rather by the mental condition of the patient, who should be 
kept in a state of relative amnesia. This is determined by showing her 
some object, which she should promptly forget having seen, if sufficiently 
under the influence of the drug, but another dose should be administered 
if she possess any recollection of it thirty minutes later. 

A very considerable literature has accumulated upon the subject, 
which has been well summarized by Lequeux, Zweifel, Siegel, and by a 
committee of the London Obstetrical Society in 1918. 

Following a magazine campaign in 1914, great interest in the pro¬ 
cedure was aroused among the laity, and obstetricians all over the country 
were constrained to experiment with the method, and a large number of 
publications of varying value have been made concerning it. 


CONDUCT OF THE SECOND STAGE OF LABOR 


363 


My own experience is that if 1/G grain of morphia and 1/150 grain 
of scopolamin be administered when the cervical canal has been oblit¬ 
erated and the external os is just beginning to dilate, followed by a sec¬ 
ond dose of 1/300 grain scopolamin one-half or one hour later, the patient 
passes into a somnolent condition, with a flushed face, injected eyes, and 
an accelerated pulse rate, and sleeps quietly, and sometimes heavily, in 
the interval between the pains, but complains bitterly during their con¬ 
tinuance. Following the second dose of scopolamin, others are adminis¬ 
tered at intervals of from one and a half to three hours, according to 
the mental condition of the patient, but the morphia or narcophen is 
not repeated unless the labor is unusually prolonged. During this period 
the patient should be kept in a dimly lighted room, from which all 
noise is excluded, her ears should be plugged with cotton and her eyes 
shaded by colored glasses, while a competent attendant should remain 
continually in the room. The dosage indicated is not sufficient to control 
the pains during the latter part of the second stage, when chloroform 
or nitrous oxid gas should be administered. Following the completion 
of labor the patient is kept in a quiet, darkened room, and upon being 
questioned at the end of three or four hours, is usually surprised to 
learn that her baby has been born, and will state that she has no recol¬ 
lection of what had occurred after the second or third injection of 
scopolamin. If the drug is not administered until late in the first stage 
of labor, the results are always disappointing, and the child is usually 
deeply asphyxiated when born. 

The desired degree of amnesia is obtained in about three-quarters 
of the patients provided a suitable technic has been developed by those 
in charge; in the remainder the results are not satisfactory, as the 
patients remember everything that has happened up to the time the 
administration of chloroform or gas was begun. It should be added that 
behavior of the patient while under the influence of the drug affords no 
indication of the degree of amnesia; as many patients become violently 
excited and complain bitterly with every pain, and yet after labor claim 
that they have no recollection of what has occurred. On the contrary, 
others, who appeared to be profoundly under the influence of the drug, 
recall every incident and contend that the labor was most painful. 

The fact that we cannot promise a satisfactory subjective result to 
more than three patients out of four makes it apparent that the method 
is not ideal, and it is my belief that it will gradually fall into desuetude, 
or at least that its use will be restricted to a small group of neurotic 
patients, upon whom it is desirable to exert a psychic effect. In addi¬ 
tion to this relative defect, several serious objections are inherent to 
this form of anesthesia. In the first place, while some of its enthusi¬ 
astic advocates claim that it slightly shortens the first stage of labor, all 
agree that it results in a definite prolongation of the second stage, 
necessitating more frequent instrumental interference, with its addi¬ 
tional danger of infection. In the second place it is attended by a 
definite, but slight, increase in the foetal mortality, estimated at between 
1 and 2 per cent., which is apparently due to direct poisoning of the 
foetus. A large proportion of the children are born in an apneic con- 




304 


CONDUCT OF NORMAL LABOR 


dition; a smaller number are deeply asphyxiated, but can be resusci¬ 
tated without great difficulty; while occasionally the asphyxia is so 
deep that resuscitation is impossible. It has no effect upon the maternal 
mortality, nor apparently upon the incidence of postpartum hemor¬ 
rhage. 

From my experience, the method is not adapted to private practice 
for three reasons. First, that it can only be expected to give ideal results 
when it is carried out by a trained personnel, under suitable material 
conditions; secondly, that in a considerable proportion of cases it is 
attended by a degree of restlessness and excitement, which may require 
physical restraint, and which makes a very painful impression upon those 
interested in the patient. Finally, it makes such demands upon the time 
and nervous equation of the physician, as to put it beyond the reach 
of all but well-to-do patients; as the already under-paid obstetrician 
cannot be expected to devote twelve or fifteen hours of continuous service 
to a normal delivery, which ordinarily requires but a few hours of his 
time. 

Lumbar Anesthesia .—Following the rehabilitation hy Bier of the sub¬ 
arachnoidal injection of cocain for the production of anesthesia of the 
lower portion of the body, and its popularization by the work of Tuffier, 
it was but natural that its efficiency should be tested upon the parturient 
woman. 

The first publication concerning its employment at the time of labor 
was made in August, 1900, by Kreis. Since then a number of observers 
have reported series of cases treated in this manner with cocain or some 
of its derivatives, and their work was well summarized by Muller in 
1905. From their reports, as well as from personal observation, there 
is no doubt that most striking results are obtained in a certain pro¬ 
portion of cases. 

In favorable cases, the patient being in the second stage of labor, 
the injection into the lumbar portion of the vertebral canal of 10 to 15 
minims of a 1 per cent, solution of novocain (1/10 to 1/6 grain) is fol¬ 
lowed within a few minutes by complete abolition of painful sensations. 
At the same time, the patient continues to make visible expulsive efforts 
with great regularity and ofttimes with increased frequency, so that, if 
the effects of the drug do not wear off too rapidly, the child may be 
expelled without pain and almost without the knowledge of the patient. 
Likewise, various operative procedures, such as manual dilatation of 
the cervix, version, or forceps, may be painlessly performed. 

I shall not enter into the details of its technic, as I advise strongly 
against its employment for the following reasons. In the first place, 
the results are not always uniform, a certain number of patients appear¬ 
ing to be refractory to the influence of the drug wffien administered in 
doses consistent with safety. Again, its effects are sometimes very 
transient and fade away just when most needed. More serious, how¬ 
ever, are the after-effects, the majority of patients suffering severely 
from headache and nausea, and frequently from an alarming, but 
transient, elevation of temperature. The most serious objection, how¬ 
ever, is the fact that Hahn reported 8 deaths in 1,708 cases in which 


REPAIR OF THE LACERATED PERINEUM 


365 


its use had been recorded in the literature. No doubt, in several in¬ 
stances the fatal issue could not be fairly attributed to the method, but 
in several others the autopsy showed lesions of the spinal or cerebral 
meninges which could be due only to infection. 

Hypnotism .—From time to time, various observers, among whom 
may be mentioned Leichstein, and Cocke, have reported instances 
in which labor was painlessly conducted under the influence of hypnotism. 
Latterly, its employment has been resumed, and in 1922 Schultze- 
Rhonhof, Kirsten and others have reported a series of cases in which 
it was used with extraordinary success. Personally I have seen it 
employed successfully in a single instance, and consider that its field 
of usefulness is very limited, for the reason that the patient must be a 
i susceptible subject, and one who has already been hypnotized on previous 
occasions. 

- 1 - The Use of Ergot and Pituitary Extract .—In the past many authori¬ 
ties recommended the administration of a dram of fluid extract of enrot 
by mouth immediately after the expulsion of the placenta, as a prophy¬ 
lactic measure against postpartum hemorrhage, and at present many 
administer hypodermatically one cubic centimeter of pituitary extract 
for the same purpose. Ordinarily, both are unnecessary, and, while it 
has already been stated that the use of the latter is permissible, I 
strongly advise against the employment of the former. If, however, the 
uterus remains soft and flabby after massage, instead of forming a hard 
tumor beneath the umbilicus, the use of pituitary extract is imperative, 
and, if bleeding occurs, I follow it by the hypodermatic injection of 40 
to 60 minims of ergotole, or some other reliable preparation of ergot, 
for the reason that one reenforces the other—as the action of pituitary 
extract is almost immediate, but only continues for a few minutes, while 
that of ergot is more tardy, but also much more persistent, so that the 
effect of the former is almost exhausted by the time that of the latter 
becomes manifest. 

This is the only time at which ergot should be employed in labor, as 
its administration before the completion of the third stage has led to 
untold harm. Formerly, even well-trained physicians used it in large 
quantities during the second stage to stimulate uterine contractions, but 
at the present time it is so employed only by ignorant midwives. The 
premature use of the drug readily leads to tetanic contractions of the 
uterus, which in the presence of any marked disproportion between the 
size of the child and pelvis are likely to bring about rupture of the 
uterus. Moreover, its administration in the third stage of labor, before 
the expulsion of the placenta, cannot be too strongly deprecated, as the 
resulting tetanic contraction tends rather to produce a further retention 
of the organ, so that its manual removal frequently becomes imperative. 

Conduct of the Third Stage of Labor.— This subject has already been 

considered in the preceding chapter. 

Repair of the Lacerated Perineum.— Strictly speaking, this subject 
should be deferred until the obstetrical operations are dealt with; but 
as perineal tears are of such frequent occurrence, and as they are best 
repaired in the interval between the birth of the child and the expulsion 





366 


CONDUCT OF NORMAL LABOR 


of the placenta, the proper method of procedure will be considered at this 
time. 

For convenience in description, perineal tears are divided into three 
groups, those of the first, second, and third degrees, lo the fiist belong 
those which involve simply the fourchette and anterior margin of the 
perineum, giving rise to a small, triangular wounded suiface which is 

rarely more than 1.5 centimeters deep. 

In the second the laceration extends through a greater or lesser por¬ 
tion of the perineal body, and frequently exposes the sphincter ani 



muscle. Usually its course does not quite follow the median line, but 
extends obliquely downward and outward from the posterior margin of 
the vulva. The perineal tear is usually associated with lesions of the 
vagina, which extend up one or both sulci, so that a triangular portion of 
the vaginal mucosa, which represents the inferior extremity of the poste¬ 
rior column, may become separated from the rest of the canal. 

In the third degree, the tear extends completely through the perineal 
body and the sphincter ani muscle, and for a certain distance up the an¬ 
terior wall of the rectum, thus giving rise to a cloaca, into which both 
vagina and rectum open. These are designated as complete, in contra¬ 
distinction to those of the first and second degrees—the incomplete tears 
—in which the rectum is not involved. Incomplete tears are encountered 
very often in the practice of the most competent obstetricians, no matter 
what precautions may be taken to prevent them; but the frequent oc¬ 
currence of the complete variety indicates that the method employed 




















REPAIR OF THE LACERATED PERINEUM 


367 




foi protecting the perineum has been at fault in spontaneous, or that 
the extraction has been too hasty in operative, deliveries. 

In tears of the first degree, the mucous membrane of the fourchette 
and the skin covering the upper portion of the perineum and the sub¬ 
cutaneous tissue are implicated; in 
those of the second degree the skin 
surface of the perineum, the vari¬ 
ous perineal muscles, particularly the 
constrictor vaginae and transversus 
perinei, are torn through, and the 
wide gaping wound is due in great 
part to the retraction of these mus¬ 
cles. When the tear extends up the 
vagina, the levator ani muscle may 
likewise be involved; while, in lacer¬ 
ations of the third degree, the 
sphincter ani muscle and the an¬ 
terior surface of the rectum are im¬ 
plicated in addition to the structures 
above named. 

In the rare cases in which the 
vulval outlet looks markedly upward, 
or in which the perineum is ex¬ 
treme! v resistant and the mechanism 
*/ 

of expulsion faulty, the laceration 
may begin in the central portion of 
the perineum, when the head appears 
in an opening which is surrounded 

on all sides by skin. This is known as a central tear , and is of infre¬ 
quent occurrence. Ordinarily, as the head is forced down still farther, 
the tear extends toward the fourchette or toward the anus, or even in 
both directions, and thus gives rise to a deep incomplete, or to a com¬ 
plete, laceration as the case may be. 

In not a few cases, where the vaginal 
opening is very resistant, and when the 
head has remained a long time upon the 
pelvic floor, even although there may be 
no external wound or appreciable lesion 
of the vagina, there may nevertheless 
have occurred a submucous tear or sepa¬ 
ration of certain fibers of the levator ani 
muscle, which will later give rise to a 
marked relaxation of the vaginal outlet. Frequently the condition, 
although unrecognized at the time, later gives rise to such aggravated 
symptoms as to call for operation years after the birth of the child. 

No matter what the degree, the immediate closure of perineal lacer¬ 
ations by suture is urgently indicated. Even slight tears through the 
fourchette are better repaired than left alone. In more extensive tears 
immediate repair is always necessary, unless the condition of the patient 


Fig. 322.—Complete Perineal Tear. 


Fig. 323.—Needle for Repairing 
Perineal Tears. 
















368 


CONDUCT OF NORMAL LABOR 


be so serious as to contra-indicate further operative procedures. For 
these operations, the patient should be brought to the edge of the bed 
and placed in the lithotomy position, and the sutures introduced- while 
waiting for the expulsion of the placenta. If non-absorbable sutures are 
employed, they should not be tied until the completion of the third 
stage, as the distention of the vulva by the placenta may subject the 
repaired wound to undue strain. By introducing the sutures during this 
period time is saved, and the temptation to hasty expression of the 
placenta is diminished, since the physician has something to do while 
waiting for the fundus to rise up. 

The mode of repair differs according as the tear extends only 
through the perineal body or is complicated by lacerations of the vagina 
or rectum. In the first case, the wound should be closed by deep sutures 
of silkworm gut, or 40 day chromic catgut, which are introduced a 
centimeter from one margin and carried well down under its base, being 
then brought out through the skin surface on the opposite side. It is 
important that the sutures should be inserted at a considerable distance 



from the edges of the wound, for, owing to the edema which de¬ 
velops later, they are very prone to tear through unless this pre¬ 
caution be taken. They should be placed at intervals of about. 1 centi¬ 
meter, and if accurate approximation is not secured superficial sutures 
should be placed between them. Large curved needles, which can make 
the entire sweep in a single movement, should be used, as they render 
much better service than small needles which require several bites. The 
sutures should be tied very loosely from below upward, and cut off 
short. 

When the perineal tear is complicated by laceration of the vagina, the 
edges of the latter should be brought together by chromicized catgut 
sutures, just as in Emmet’s relaxed outlet operation. These may be 
either interrupted or continuous, but in either event they should be laid 
deeply in order to insure coaptation of the torn structures of the pelvic 
floor, instead of merely bringing together the edges of the mucosa, after 
which the perineal wound should be repaired in the usual manner. 

In complete tears, attention should first be given to the wounded 
rectum and its ruptured mucosa united by buried catgut sutures. Then 
the ends of the sphincter ani should be isolated and firmly sutured by 
catgut or fine silk sutures, after which the vaginal and perineal tears 
should be dealt with in the manner indicated above. Whenever catgut 
sutures are employed in any but the most superficial tears, it is advis¬ 
able to place one or two deep silkworm gut sutures as a precautionary 







REPAIR OF THE LACERATED PERINEUM 


369 


measure, as even forty day chromic catgut sutures may be absorbed pre¬ 
maturely. 

The after-treatment of tears of all degrees is comparatively simple, 
and consists in keeping the wound clean and covered by sterile dressings. 
The wounded surface should be washed several times a day with plain 
water or a 1 to 4,000 bichlorid solution, as Plass in our service demon¬ 
strated that the elaborate technic formerly employed is unnecessary, and 
only adds to the discomfort of the patient. For this reason the use of 
antiseptic powders, such as iodoform or boric acid, is not indicated, as 
the wounds heal equally well without them. Nor is there any necessity 



Fig. 325.—Repair of Ferineal Tear 
Extending up the Vagina. 


Fig. 326.—Same, Sutures Tied. 


for binding the legs together, unless the patient is very unruly. Catheter¬ 
ization should be dispensed with, except in cases of retention, as the 
flow of urine over the wound does no harm, provided it is followed by 
proper cleansing. Generally speaking, the external sutures should be 
removed on the tenth day. In tears of the first and second degrees 
the bowels should be moved daily, but in complete lacerations it is ad¬ 
visable to prevent an action for the first four or five days, after which 
a large high enema of sweet oil should be given, followed by one ounce 
of castor oil by the mouth. 

The results following these operations are usually very satisfactory, 
and primary union is the rule, provided the sutures have been intioduced 
far enough from the margins of the wound and not tied too tightly. 
This is a point to which too much attention can hardly be paid, for too 
often there is a tendency to attempt to make a neat-looking operation 























370 


CONDUCT OF NORMAL LABOR 


by introducing the sutures close to the margins of the wound and tying 
them snugly. As a result, the majority of the stitches cut through and 
become useless. On the other hand, when less attention is paid to the 
first appearance of the wound, the sutures being introduced far from its 
margins and tied somewhat loosely, excellent results almost always 
follow. 

Unfortunately, operations for complete tears are by no means so satis¬ 
factory, and, as a general rule, not more than two-thirds of the cases 
heal by first intention. In the cases of complete or partial failure a sec¬ 
ondary operation is indicated before the patient is discharged from treat¬ 
ment. 


LITERATURE 

Bier. Versuche iiber Coeainisirung ties Riickenmarkes. Deutsche Zeitschr. f. 
Chirurgie, 1899, li, 361. 

Budin. A quel moment doit-on operer la ligature du cordon ombilical? Le Progres 
medical, 1875, decembre; 1876; janvier. (Obstetrique et Gynecologie, 1886, 
1-35.) 

Channing. A Treatise on Etherization in Childbirth. Boston, 1848. 

Davis. Painless Childbirth, Eutocia and Nitrous Oxid Oxygen Analgesia. Chicago, 
1916. 

Doniioff. Ueber die Einwirkung ties Chloroforms auf den normalen Geburtsver- 
lauf, etc. Archiv f. Gyn., 1892, xlii, 305-328. 

Furbringer. Untersuchungen und Yorschriften iiber die Desinfection der Hande 
des Arztes, nebst Bemerkungen iiber den bakteriologischen Character ties 
Nagelschmutzes. Wiesbaden, 1888. 

Gauss. Geburten im kiinstlichen Dammerschlaf. Archiv f. Gyn., 1906, lxxviii. 
579-631. 

Die Teclmik ties Skopolamin-morphium Dammerschlafes in der Geburtshilfe. 
Zentralbl. f. Gyn., 1907, xxxi, 33-38. 

Giffard. Cases in Midwifery. London, 1734, 396-398. 

Goodell. A Critical Inquiry into the Management of the Peringeum during Labor. 
Amer. Jour. Med. Sciences, 1871, lxi, 53-79. 

Hahn. Ueber subarachnoideale Cocaininjectionen naeh Bier. Centralbl. f. d. 
Grenzgebiete tier Med. u. Chirurgie, 1901, iv, 304-317 und 340-354. 

Harvie. Practical Directions Showing a Method of Preserving the Perineum in 
Childbirth, etc. London, 1767. 

Hensen. Ueber den Einfluss des Morphiums und ties ZEthers auf die Wehen- 
thatigkeit ties Uterus. Archiv f. Gyn., 1898, lv, 129-177. 

Johnston and Siddall. Is the Usual Method of Preparing Patients Beneficial 
or Necessary? Am. J. Obst. & Gyn., 1922, iv, 645-650. 

Kelly. Hand Disinfection. Amer. Jour. Obst., 1891, xxiv, 1414-1419. 

Kirstein. Ueber Hypnosegeburten und Hypnonarkosen. Zentralbl. f. Gyn., 1922, 
943-850. 

Kreis. Ueber Medullarnarkose bei Gebarenden. Zentralbl. f. Gyn., 1900, xxiv, 
724-729. 

Kronig. Versuche fiber Spiritusdesinfection der Hande. Zentralbl. f. Gyn., 1894, 
xiii, 1346-1353. 

Lequeux. La scopolamine en obstetrique. L’obst., 1911, N. S. iv, 165-234. 

Lynch. Eutocia by Means of Nitrous Oxid and Oxygen Analgesia. Illinois 
Med. Jour., April, 1915. 


LITERATURE 


371 


Muller. Ueber Lumbalanasthesie in tier Geburtshiilfe u. Gynakologie. Monatsschr. 
f. Geb. u. Gyn., 1905, xxi, 169-185. 

Olshausen. Ueber Dammverletzung und Dammschutz. Volkmann’s Sammlung 
klin. Vortrage, 1872, Nr. 44. 

Plass. Post-partum Care of the Perineum. Bull. Johns Hopkins Hosp., 1916, 
xxvii, 107-109. 

Pomeroy. Shall We Cut and Reconstruct the Perineum for Every Primipara? 
Am. Jour. Obst., 1918, lxxviii, 211-220. 

Report of the Committee Appointed to Investigate the Effects of Scopolamine- 
morphine Narcosis. Trans. Roy. Soc. of Med. (Gyn. and Obst. section), 
1918, xi, 1-44. 

Ritgen. Ueber ein Dammschutzverfahren. Monatsschr. f. Geburtsk., 1855, vi, 
321-347. 

Siegel. Schmerzlose Entbindungen im Dammerschlaf, etc. Deutsche med. Wochen- 
schr., 1914, 1049-53. 

Schroeder. Lehrbuch tier Geburtshiilfe, VII. Aufl., 681. 

Schucking. Zur Physiologie der Nachgeburtsperiode. Berliner klin. Wochen- 
sc.hr., 1877, xiv, 5, 18. 

Schultz-Rhonhof. Der hypnotische Geburtsdammerschlaf. Zentralbl. f. Gyn., 
1922, 843-850. 

Simpson. On the Employment of the Inhalation of Sulphuric Ether in the Practice 
of Midwifery. Monthly Jour, of Med. Sciences, 1847, vii, 728. 

Anaesthesia. Philadelphia, 1849, 248. 

Steinbuchel. Yorlaufige Mittheilung liber die Anwendung Skopolamin-morphium- 
Injektionen in der Geburtshiilfe. Zentralbl. f. Gyn., 1902, xxvi, 1304-1306. 

Schmerzverminderung in der Geburtshilfe, etc. Leipzig u. Wien, 1903. 

Tuffier. L ’anesthesie medullaire en gynecologie. Revue tie gyn. et tie cliir. 
abd., 1900, iv, 683-692. 

Webster. Nitrous Oxid Gas Analgesia. Jour. Am. Med. Assn., 1915, lxiv, 812- 
813. 

Williams. The Cause of the Conflicting Statements Concerning the Bacterial 
Contents of the Vaginal Secretion of the Pregnant Woman. Amer. Jour. 
Obst., 1898, xxxviii, 807-817. 

Zweifel. Ueber den Dammerschlaf, etc. Monatsschr. f. Geb. u. Gyn., 1912, xxxvi, 
Ergranzungs Heft 258-301. 








CHAPTER XVI 


THE PUERPERIUM 

Strictly speaking, the term puerperium or puerperal state (from 
puer, a child; and parere, to bring forth) comprises the period elapsing 
between the onset of labor and the return of the generative tract to its 
normal condition; but in common parlance it is restricted to the five 
or six weeks following the completion of labor. Although the changes 
occurring during this period are considered as physiological, they border 
very closely upon the pathological, inasmuch as under no other circum- 



Fig. 327. —Frozen Section, Showing Uterus Immediately After Delivery (Webster). 


stances does such marked and rapid tissue metabolism occur without 
a departure from a condition of health. 

Anatomical Changes in the Puerperium .—Involution of the Uterus .— 
Immediately following the expulsion of the placenta, the contracted and 
retracted body of the uterus forms a hard muscular tumor, the apex 
of which lies about midway between the umbilicus and symphysis, usu¬ 
ally 12 centimeters (4% inches) above the latter. At autopsy, shortly 
after labor, it consists of an almost solid mass of tissue containing 
in its center a flattened cavity, whose anterior and posterior walls 
are in close apposition, each of which measure four to five centimeters 
in thickness. On section, the nterus presents a markedly anemic appear¬ 
ance as compared to the pregnant organ, which, according to Webster 
and Longridge, is due to compression of its vessels by the contracted 

372 




ANATOMICAL CHANGES IN THE PUERPERIUM 


373 


and retracted muscular fibers. At the same time a considerable portion 
of the tissue juices is expressed. During the next two days the uterus 
remains apparently stationary in size, after which it atrophies so rapidly 
that by the tenth day it has descended into the cavity of the true pelvis, 
and can no longer be felt above the symphysis. It regains its normal 
size by the end of five or six weeks. Some idea of the rapidity with 
which the process goes on may be gained by recalling the fact that the 
freshly delivered uterus weighs about 1,000 grains, one week later 500 
grams, at the end of the second week 375 grains, and at the end of the 
puerperium only 40 to 60 grams. 

This rapid decrease in size is due to what is designated as involution, 
and is the most striking example of atrophy with which we are ac¬ 
quainted; in that the organ becomes reduced to one-twentieth or one- 
twenty-fifth of its original size within a few weeks, and, when compared 
with the changes occurring in acute yellow atrophy of the liver, may 
well be designated as “atrophia acutissima.” 

It was formerly believed that the muscle cells underwent fatty de¬ 
generation during involution, and that large numbers of them com¬ 
pletely disappeared. Sanger, however, was the first to show that 
only the excess of protoplasm is removed, and that the actual num¬ 
ber of individual cells is not materially diminished. In other words, 
they undergo marked atrophy, but are not destroyed. Sanger estimated 
that their average length in the full-term uterus was 208.7 microns, as 
compared with 24.4 microns five weeks after labor. 

It is now held that involution is effected by autolyic processes, by 
which the protein material of the uterine wall is in great part broken 
down into simpler components, which are then absorbed and eventually 
cast off through the urine. The evidence in favor of such a view is 
principally afforded by the study of the nitrogen content of the urine. 
For the twenty-four hours immediately following labor 7 to 9 grams of 
nitrogen are excreted, but some time during the second or third day an 
increase of 30 to 50 per cent, is noted. This excessive output continues 
for a number of days, but gradually returns to normal at about the 
times the uterus has disappeared into the pelvic cavity. 

That this phenomenon is not entirely attributable to the removal of 
other products of pregnancy was clearly shown by Slemons, who, in one 
of my patients, from whom the uterus had been removed at cesarean sec¬ 
tion, found that the characteristic increase in the nitrogen output was 
lacking, and that the deficit practically corresponded to the quantity of 
nitrogen found upon analyzing the uterus. 

As yet we know nothing of the ferments giving rise to the autolysis, 
but it is readily conceivable that their action is facilitated by the acute 
anemia of the “blood-tight” uterus. Morse, who has studied the metabo¬ 
lism of the puerperium, found that the creatinin content of the urine 
becomes markedly increased during the first few weeks and later re¬ 
turns to its normal level. He associates this with the process of in¬ 
volution, as he found that it was much less in two patients from whom 
the uterus had been removed by Porro’s cesarean section. He also con¬ 
firmed the statement of Murlin that considerable quantities of creatin 


374 


THE PUERPERIUM 


appear in the urine, blit was unable to determine its source. At the 
same time, by comparing the metabolism in normal puerperal women 
with that occurring after the removal of the uterus, he was able to show 
that its excretion is in no way dependent upon the process of involution, 
and that it is likewise independent of the creatinin metabolism. 

As has been said before, the separation of the placenta and its mem¬ 
branes occurs in the outer portion of the spongy layer of the decidua, 
and accordingly a remnant of the latter remains in the uterus after their 
expulsion. It presents striking variations in thickness, an irregular, 
jagged appearance, and is markedly infiltrated with blood, especially 
at the placental site. As the result of hyaline and fatty degeneration, 
the greater portion of this tissue is cast off in the lochia, leaving behind 
only the fundi of the glands and a minimal amount of connective tissue, 
from which the new endometrium is regenerated 

The processes concerned in its regeneration have been carefully 
studied by Friedlander, Kundrat and Engelmann, Leopold, Kronig, and 
particularly by Wormser. The latter has shown that, within two or 
three days after labor, the portion of decidua remaining in the uterus 
becomes differentiated into two layers—one adjoining the uterine cavity 
being necrotic, and the other adjoining the muscularis being well pre¬ 
served. The former is cast off in the lochia, while the latter, which 
contains the fundi of the glands, remains in situ and constitutes a 
matrix from which the new endometrium is regenerated, its epithelium 
resulting from the proliferation of the gland cells, and its stroma from 
the connective tissue between them. For the first ten days or two 
weeks degenerative processes predominate, but after that mitotic figures 
appear and regeneration is rapid, the new endometrium being fully 
formed by the end of the third week, except at the placental site, where 
the process is more gradual. 

Changes in the Uterine Vessels .—Immediately after the completion 
of the third stage of labor, the placental site is represented by an irregu¬ 
lar, nodular, elevated area of about the size of the palm of the hand, the 
elevations being due to the presence of thrombosed vessels. This area 
decreases rapidly in size, so that it measures 3 or 4 centimeters in diam¬ 
eter at the end of the second week, and only 1 to 2 centimeters at the 
completion of the puerperium, although it still remains elevated above 
the general surface of the interior of the uterus and is tinged with blood 
pigment. Its original position remains recognizable for quite a long 
period, and even six months after childbirth appears as a slightly ele¬ 
vated pigmented area. 

According to Hinselmann, with whom I agree, the sinuses at the 
placental site do not undergo thrombosis during pregnancy, but the 
process becomes inaugurated during the latter portion of the second 
and particularly after the completion of the third stage of labor, al¬ 
though many sinuses never become thrombosed, but are simply com¬ 
pressed by the contracting uterine muscles. The thrombi become organ¬ 
ized by the proliferation of the intima of the vessels, and eventually are 
converted into typical connective tissue. 

As the pregnant uterus requires a much more abundant blood supply 



ANATOMICAL CHANGES IN THE PUERPERIUM 


375 


than the non-pregnant organ, it is apparent that after delivery the lumina 
of its arteries must undergo a corresponding diminution in caliber. 
Formerly it was thought that this was brought about by a compensatory 
endarteritis, which disappeared in subsequent pregnancies. Now, how¬ 
ever, the prevailing belief is that the larger vessels are completely 
obliterated by hyaline changes, and that new and smaller vessels develop 
in their stead. The absorption of the hyaline material is accomplished 
by piocesses similar to those observed in the ovaries, although the 
changes may persist for years, and under the microscope offer a ready 
means of differentiating between the uteri of women who have, and 
those who have not, borne children. For details, the student is referred 
to the articles of Pankow, Goodall, Biittner, and Schwartz. 

Changes in the Cervix, Vagina, and Vaginal Outlet. —Immediately 
after the completion of the third stage, the cervix is represented by a 



Fig. 328. —Frozen Section Just after Completion of Third Stage of Labor, Show¬ 
ing Collapse of Lower Uterine Segment and Cervix (Benckiser) 

C.R., contraction ring; O.E., external os; O.I., internal os. 

soft, muscular tube, whose boundaries can be made out only with 
difficulty. The margins of the external os are soft and flabby, and are 
usually marked by depressions indicating the seat of lacerations. Its 
opening contracts slowly. For the first few days immediately following 
labor it readily admits two fingers, but by the end of the first week it 
has become so narrow as to render difficult the introduction of one 
finger. At the same time the lower uterine segment collapses, and 
what remains of the contraction ring comes in contact with the upper 
portion of the cervical canal. As Webster has pointed out, there is no 
doubt that the structure which is usually taken for the internal os on 
digital examination really represents the lower margin of the contrac¬ 
tion ring (Fig. 328). 

The vagina requires some time to recover from the distention to 
which it has been subjected. In the first part of the puerperium it is 















376 


THE PUERPERIUM 


represented by a capacious, smooth-walled passage, which gradually 
diminishes in size, though it rarely returns to its virginal condition. The 
rugae begin to reappear about the third week. The vaginal outlet is 
also markedly distended, and in primiparae usually bears signs of more 
or less extensive laceration. The hymen, as such, has disappeared, and 
its place is taken by a number of small tags of tissue, which, as the 
process of cicatrization goes on, become converted into the carunculae 
myrtiformes, which are characteristic of the vaginal opening of parous 
women. The labia majora and minora become flabby and atrophic, as 
compared with their condition before childbirth. 

Changes in the Peritoneum and Abdominal Wall. —While these 
changes are taking place in the uterus and vagina, the pelvic peritoneum 
and the structures of the broad ligaments are accommodating themselves 
to the changed conditions of affairs. For the first few days after labor 
the peritoneum covering the uterus is arranged in folds, which soon 
disappear. The broad and round ligaments are much more lax than in 
the non-pregnant condition, and require considerable time to recover 
from the stretching and loosening to which they have been subjected. 

As a result of prolonged distention due to the presence of the 
enlarged pregnant uterus, the abdominal walls remain soft and flabby 
for some time. Except for the presence of silvery striae, they gradually 
return to their normal condition if the abdominal muscles have retained 
their tonicity; but when this is much impaired they never regain 
their original consistency, but remain lax and flabby. In not a few 
instances, particularly in women who have borne a number of children 
in rapid succession, there may be a marked separation or diastasis of 
the recti muscles , so that a considerable portion of the abdominal contents 
is covered simply by peritoneum, thmned-out fascia, and skin. 

The changes occurring in the breasts are very characteristic, and will 
be considered in Chapter XVII. 

Clinical Aspects of the Puerperium.— Postpartum Chill. — Quite fre¬ 
quently the patient may have a more or less violent rigor, coming on 
shortly after the completion of the third stage of labor. This is a 
nervous or vasomotor phenomenon, and is without prognostic signifi¬ 
cance. In this respect it stands in marked contrast to a chill occurring 
later in the puerperium, which nearly always indicates the onset of an 
acute infectious process. 

Temperature. —The temperature should remain practically normal 
during the puerperium; hence any considerable rise should always be 
regarded as abnormal, and considered as a sign of infection until con¬ 
vincing evidence to the contrary can be adduced. Occasionally the tem¬ 
perature may become slightly elevated toward the end or just after the 
completion of a difficult labor, but rarely goes above 100° F. (38° C.), 
usually falls to normal within twelve hours, and does not rise again. 
A higher temperature during labor usually indicates intrapartum in¬ 
fection, associated with bacterial invasion of the foetal membranes and 
the liquor amnii. 

Owing to the fact that slight rises of temperature occur frequently 
during the puerperium without apparent cause, it is customary to desig- 





CLINICAL ASPECTS OF THE PUERPERIUM 


377 


liate as normal all puerperia in which the temperature remains below 
100.4° F. (38° C.), and as febrile all those in which that limit is reached 
or exceeded in two different days. 

It was formerly believed that the establishment of the lacteal secre¬ 
tion on the third or fourth day of the puerperium was naturally attended 
by a slight rise in temperature. Indeed, so prevalent was this idea that 
in pre-antiseptic times the so-called millc fever was regarded as a normal 
phenomenon. At present we no longer believe in the existence of 
such a pathological entity, and whenever the temperature exceeds the 
arbitrary normal limit at this time the conscientious obstetrician should 
fear the beginning of an infection, and begin to search for the errors 
of technic which may have led to it. 

Pulse .—During the puerperium the pulse is usually somewhat slower 
than at other times, averaging between 60 and 70. In nervous women, 
however, and in those who have had difficult labors or have suffered any 
considerable loss of blood, a more rapid rate than normal is not infre¬ 
quent. In a certain number of cases, a day or two after the birth of the 
child, the pulse becomes markedly slower, and sometimes falls to 50, 
40, or even fewer beats to the minute. Fehling has reported a case 
in which the rate was only 36. 

Ordinarily this phenomenon becomes most marked on the second or 
third day, after which the pulse becomes quicker and attains its normal 
rate by the end of the first week or ten days. The slow pulse is usually 
regarded as a favorable prognostic sign, whereas a rapid heart action, 
unless it can be accounted for by hemorrhage or cardiac disease, should 
be looked upon with suspicion. 

This puerperal bradycardia is usually regarded as a characteristic 
phenomenon. Heil, however, in 1898, stated that he observed it in only 
12 per cent, of his cases. He affirmed that if the pulse be carefully 
counted in the same patient for some days before, as well as after, labor, 
it will usually be found slightly quicker in the puerperium than during 
pregnancy. Yarnier’s investigations failed to confirm HeiTs conclusions, 
since they showed that the puerperal slow pulse occurred in 72 per cent, 
of the cases. In a series of patients in my service, reported by Lynch, in 
which the pulse rate was recorded during pregnancy, as well as during the 
puerperium, a slowing of ten or more beats per minute was noted in 20.5 
per cent., and occurred more than twice as frequently in multiparous 
as in primiparous women. 

Numerous theories have been advanced from time to time in the 
attempt to explain its mode of production, but none of them is wholly 
satisfactory. It is not impossible that the solution is quite simple, and 
that the condition may depend upon two factors: the absolute rest of 
the patient in bed, together with the great diminution in work which the 
heart is called upon to perform after the elimination of the uteroplacental 
circulation. Kehrcr attributed the slowing in great part to the lowering 
of the blood pressure following delivery; Schroeder, to the sudden dim¬ 
inution of the vascular area after the uteroplacental circulation is thrown 
out of function; Fritsch, to the horizontal position and rest in bed; Loh- 
lein, to stimulation of the vagus or other nervous influences ; Olshausen, 


378 


THE PUERPERIUM 


to the absorption of various products set free in the blood during the 
involution of the uterus; and Novak and .letter, to vagus stimulation. 

Changes in the Blood .—It is usually stated that there is a slight de¬ 
crease in the number of red corpuscles and the amount of hemoglobin, 
attributable to the loss of blood immediately following delivery. Obser¬ 
vations upon the blood volume made in our clinic by Harris, but not 
yet published, indicate that this statement is incorrect. He has found 
that the blood volume is increased during pregnancy, giving rise to a 
relative hydremia, which is associated with a lowered blood count and 
hemoglobin content. Immediately following labor, however, the blood 
volume undergoes an acute concentration, with the result that the cellular 
constituents, as well as the hemoglobin content, are increased, and after¬ 
wards slowly return to the normal non-pregnant proportions. 

Hofbauer has directed attention to the occurrence of a marked leuko¬ 
cytosis occurring during and just after labor. He showed that the 
leukocytes gradually increase in number from the onset of labor and 
reach a maximum ten or twelve hours after its conclusion, at which time 
they are nearly twice as abundant as during pregnancy. Having at¬ 
tained their acme, they promptly fall to normal, rising again slightly on 
the third or fourth day, with the establishment of the lacteal secretion, 
after which they remain at the normal level. 

After-pains .—In primiparous women the uterus remains in a state 
of tonic contraction and retraction during the puerperium, unless it has 
been subjected to unusual distention, or blood clots or other foreign 
bodies have been retained in its cavity, as a consequence of which active 
contractions occur in the effort to expel them. In multiparous women, 
on the other hand, the uterus has lost part of its initial tonicity, so that 
persistent contraction and retraction cannot be maintained, and con¬ 
sequently it contracts and relaxes at intervals, the contractions giving 
rise to painful sensations, which are known as after-pains, and which 
occasionally are so severe as to require the administration of a sedative. 
In many patients these are particularly noticeable when the child is put 
to the breast, and may last for many days, but ordinarily they lose their 
intensity and become quite bearable after the twenty-four hours imme¬ 
diately following delivery. 

Lochia .—During the first part of the puerperium there occurs nor¬ 
mally a variable amount of vaginal discharge—the lochia. For the first 
few days after delivery it consists of blood-stained fluid —lochia rubra; 
after three or four days it becomes paler —lochia serosa; and after the 
tenth day, owing to a marked admixture with leukocytes, it assumes a 
whitish or yellowish-white color —lochia alba. It is alkaline in reaction, 
and has a peculiar fleshy odor, suggesting fresh blood. In normal cases 
its total quantity varies between 500 and 1,000 grams, being less profuse 
in women who suckle their children. Foul-smelling lochia indicate in¬ 
fection with putrefactive bacteria. In many instances the reddish color 
is preserved for a longer period, but when it persists for more than two 
weeks, it indicates the retention of small portions of the after-birth, 
or imperfect involution, which is frequently associated with retroflexion 
of the uterus. When examined under the microscope during the first few 


CLINICAL ASPECTS OF THE PUERPERIUM 


379 


days, the lochia consist of red blood corpuscles, leukocytes, fatty epithelial 
cells, and shreds of degenerated decidual tissue. 

Microorganisms can always be demonstrated in the vaginal lochia, 
but are not always present when the discharge is obtained from the 
uterine cavity. The investigations of Doderlein, Kronig, Little, and 
myself have shown that normally the latter does not contain bacteria 
during the first few days of the puerperium, but that they occur with 
increasing frequency as it advances. They are not, however, of the 
pyogenic varieties, except in cases of infection. Furthermore, Kronig 
has demonstrated that the normal vaginal lochia, although rich in 
harmless parasites, do not contain pyogenic organisms, with the exception 
of gonococci. He also showed that the bacterial flora of the vagina 
undergoes a marked changed during the puerperium, when the bacilli, 
which predominated during pregnancy, are in great part replaced by 
cocci. This change is probably due to the altered reaction of the 
secretion, which is markedly acid before, and alkaline after, labor. 

General Functions .—The function of the skin is markedly accen¬ 
tuated, as is demonstrated by the profuse sweating which frequently 
characterizes this period. It is most marked at night, and it is not 
unusual for the patient to awake from a sound sleep to find her night¬ 
gown drenched with perspiration. It passes off spontaneously and does 
not require treatment. 

The appetite is usually diminished during the first few days after 
labor, and the patient experiences little desire for nutritious food. At 
the same time, owing to the marked diaphoresis and the quantity of 
fluid lost through the lochial discharge, thirst is considerably increased. 

The bowels are nearly always constipated during the first part of 
the puerperium. This is due partly to the fact that the patient eats but 
little solid food, but principally to the relaxation of the abdominal walls 
and their consequent inability to aid in evacuating the intestinal con¬ 
tents. 

Urine .—There is a marked increase in the urinary output during the 
puerperium. More important, however, are the changes in the composi¬ 
tion of the urine, to which reference was made on page 373, and which 
afford an index to the profound changes in metabolism which charac¬ 
terize this period. 

In the majority of cases the examination of urine, removed by cathe¬ 
terization immediately after the completion of labor, shows a slight 
amount of albumin and numerous hyaline casts, even though both may 
have been absent throughout pregnancy. In a series of patients studied 
in my service by Little, traces of albumin were noted in 89 per cent., 
and casts in 41 per cent. This is a transient phenomenon resulting 
from the systemic strain caused by labor, and usually disappears within 
twenty-four hours, though in a certain number of cases traces of albumin 
persisted for some days, but always disappeared by the end of the second 
week, unless the patients were suffering from toxemia or chronic ne¬ 
phritis. It should be remembered that such statements apply only to 
urine obtained by catherization, as voided specimens always contain 
albumin so long as the lochia persist. 


380 


THE PUERPERIUM 


Occasionally a small amount of sugar may be found in the urine 
during the first weeks of the puerperium. Careful investigation has 
shown that the reaction is due to the presence of lactose, or milk-sugar, 
which is supposed to be absorbed from the mammary glands, so that 
the condition has no connection with diabetes. Hey observed it in 77 
per cent, of his cases, while McCann and Turner detected it in small 
quantities in every case which they examined. In my own clinic, the 
routine weekly urinary examination in 3,000 patients showed a much 
smaller incidence—4.69 per cent. For a full discussion of the question 
the reader is referred to the section on glycosuria and diabetes in preg¬ 
nant women. 

Couvelaire, and Scholten have demonstrated that there is a marked 
increase in the amount of acetone in the urine immediately after labor, 
which disappears within the next three days. The last-named investi¬ 
gator noted it in 94 per cent, of his cases, and found that it was most 
abundant after difficult and prolonged labors. He attributes its produc¬ 
tion to the excessive breaking up of carbohydrates resulting from the 
increased muscular activity incident to parturition. 

There is a marked tendency toward retention of the urine during 
the first few days of the puerperium, and occasionally the distended 
bladder can be distinguished as a fluctuant tumor above the umbilicus. 
The retention may result from numerous causes, but is particularly apt 
to follow operative or difficult labors; and in such circumstances may be 
attributable to contusions or other slight lesions of the urethra. In 
other cases it is probably caused by the diminished intra-abdominal 
pressure, which allows a greater quantity of urine to accumulate in the 
bladder than under other conditions, as well as by the flaccidity of the 
abdominal walls and the consequent difficulty of bringing them into 
play during urination. In not a few cases it is due to the fact that 
possibly at any time the patient is unable to evacuate the bladder in the 
recumbent position. 

Loss of Weight .—In addition to the loss of 6 to 6 V 2 kilos, which 
results from the evacuation of the contents of the uterus, it is generally 
stated that tliere is a still further loss of body weight during the puer¬ 
perium, which, according to Gassner, amounts to 4,500 grams in the 
first week. Heil estimates it at 2,000, and Klemmer at only 900 grams. 
This apparent contradiction is due to the fact that GassneFs results 
were obtained at a time when the diet was greatly restricted, but at 
present, when it is more liberal, the loss of weight is much less, and 
in many instances does not occur at all if sufficient food be taken. In 
normal cases it is nearly always regained by the end of the puerperium. 

Care of the Patient during the Puerperium. — Attention Immediately 
after Labor .—After carefully examining the placenta immediately after 
its expulsion, to make sure that it is intact, the physician should devote 
his attention to watching the condition of the uterus. At this time it 
should form a hard, round, resistant tumor, whose upper margin lies 
below the umbilicus. As long as it resembles a cricket-ball in consistence, 
there is no clanger of postpartum hemorrhage, which becomes imminent 
if the uterus should grow soft and flabby. To guard against such an 



CARE OF THE PATIENT DURING THE PUERPERIUM 381 


occurrence, the uterus should be gently palpated through the abdominal 
walls immediately after the conclusion of the third stage, and the ma¬ 
neuver repeated at frequent intervals. If it is found to be tightly con¬ 
tracted, all is well; but if any tendency toward relaxation is detected, 
the organ should be grasped through the abdominal walls and vigor¬ 
ously kneaded until it remains persistently contracted; at the same time 
pituitary extract or ergot should be administered hypodermically. 

Even in normal cases, the physician should not leave the patient 
immediately after the completion of labor, but should remain within 
call for at least one hour, so as to be available should any complication 
arise. If at the end of that period the uterine contractions are satis¬ 
factory, the patient can be safely left, but, if they are not, they should 
be stimulated by appropriate measures, and the behavior of the organ 
carefully watched until the physician feels assured that all danger of 
hemorrhage has passed. Occasionally, this may necessitate a wait of 
several hours. 

Toilet of the Vulva .—Immediately after the birth of the placenta, the 
soiled linen having been removed from beneath the patient, the buttocks 
and external genitalia are cleansed with hot water and soap and bathed 
with a 1-2,000 bichlorid solution. A sterile vulval pad, made of cotton 
wrapped in gauze, is then applied over the genitalia and held in place 
by a “T” bandage, being replaced by a clean one whenever necessary. 
The number of pads required in the twenty-four hours varies according 
to the amount of lochial discharge, and affords a fairly accurate means of 
estimating its quantity. Each time the pads are changed, and after 
each movement of the bowels, the genitalia should be cleansed with fresh 
cotton pledgets soaked in bichlorid solution, care being taken that the 
parts are washed from above downward, so as to avoid contamination 
from the rectum. The use of bichlorid solution is not essential, as 
comparative observations made in my service by E. D. Plass have shown 
that, even in the presence of perineal tears, equally good results may be 
obtained by the use of boiled water. 

The vulval pad not only absorbs the lochia and prevents contamina¬ 
tion of the vulva from without, but also makes it difficult for the patient 
to touch her genitalia, a practice very common among the uneducated 
classes, and one that occasionally gives rise to infection. 

Binder .—Many authorities recommend that a tightly fitting binder 
of unbleached muslin, reaching from the trochanters to above the 
umbilicus, be applied immediately after delivery, since they hold that 
it exerts a beneficial effect upon the involution of the uterus, makes the 
patient more comfortable, and tends to restore her figure to its original 
condition. Personally, I am not in favor of its routine employment dur¬ 
ing the first days of the puerperium, as I am convinced that it has no 
influence upon the involution of the uterus, nor upon the restoration 
of the figure. On the other hand, I feel that it may retard the latter 
by inhibiting the movements of the abdominal wall; as in my experience 
the tonicity of the abdominal wall is the main factor concerned, and 
when this is seriously impaired I know nothing that will bring about 
the desired result, although massage and systematic gymnastic exercises 


382 


THE PUERPERIUM 


during the last week the patient spends in bed may do something toward 
it. If, however, the abdomen is very fat or unusually flabby, a well¬ 
fitting bandage adds materially to the comfort of the patient, and should 
be applied. 

After-pains .—Since after-pains occur in primiparae only when the 
uterus has been subjected to undue distention, it is not usually necessary 
to provide for their relief after the birth of a first child. On the other 
hand, after the delivery of a multiparous patient, it is advisable to 
leave with the nurse several tablets of 14 grain of morphin and 1/150 
grain of atropin, with instructions to administer them by the mouth 
at intervals of four or six hours, if the pains be severe. 

Best and Quiet .—As soon as the patient has been made comfortable, 
the room should be darkened and she should be encouraged to sleep. 
The relatives should be excluded, and the nurse should bathe and dress 
the baby in an adjoining apartment, if there is one at her disposal. The 
patient should be kept in bed for the first ten or twelve days, but should 
always be permitted to move freely and to sit up to make her toilet 
and to eat her meals. During this period, as a rule, only the immediate 
members of the family should be admitted to see her. Moreover, if 
these are numerous, strict instructions should be given the nurse as to 
the number of visitors each day. 

Diet .—Formerly it was the custom to restrict to a minimum the diet 
of the puerperal woman, and, as has already been said, this limitation 
goes far to explain the loss of weight which was frequently observed 
during the first few days. At present, however, a more liberal allowance 
is customary, and the patient is encouraged to take plenty of plain nour¬ 
ishing food. 

If not nauseated, she should be given a glass of milk or a cup of tea 
soon after labor. For the first few days the appetite is not vigorous, 
but small quantities of easily digested food may be taken at frequent 
intervals. I usually give the nurse the following directions: For the 
first twenty-four hours, water, milk, coffee, tea, or cocoa, boiled or 
poached eggs, and buttered or soft toast. On the second and third days 
the same, with the addition of simple soups, or bouillon, raw or stewed 
oysters, sweetbreads, chicken breast, and wine jelly. On the fourth and 
fifth days as above, with the addition of birds, steak, chops, baked pota¬ 
toes, and rice, after which the ordinary diet may be resumed. 

Temperature .—The temperature should be carefully watched during 
the first week of the puerperium, as fever is usually the first symptom 
of the onset of an infectious process. If the patient be in charge of a 
trained nurse, it should be taken four times daily—at 8 a. m., 12 m., 
4 p. m., and 8 r. m., and recorded upon a suitable chart. The physician 
should be immediately notified it it rises above 100°. But when the 
nurse is ignorant the temperature should be taken by the physician him¬ 
self, morning and evening, for the first five days. This, of course, means 
that during that time he must visit the patient twice a day, once a day 
for the following two or three days, and afterward at less frequent 
intervals. But when the nurse is competent a single daily visit will 
suffice, unless untoward symptoms develop, as the physician can rely 


CARE OF THE PATIENT DURING THE PUERPERIUM 


383 


upon being notified promptly of any change. It is always better, how¬ 
ever, whenever possible, that the patient should be seen within the first 
twelve hours following delivery. 

Urination. —The patient should be encouraged to urinate within the 
first six hours. When she is unable to do so, the catheter should not 
be employed until the bladder forms a definite tumor above the sym¬ 
physis, and not even then until the patient has attempted to urinate in 
a sitting position; inasmuch as many women are unable to use a bed- 
pan. I consider the change in position much less dangerous than 
catheterization, as the latter, no matter how carefully performed, always 
carries with it some risk of infection and of a consequent cystitis, par¬ 
ticularly as the investigations of Alsberg have shown that the normal 
urethra always harbors colon bacilli. Moreover, in not a few cases, the 
procedure, when once commenced, must be continued for a number of 
days, a condition of affairs which, leaving out of account the danger of 
infection, becomes very onerous to the physician, unless he has a com¬ 
petent nurse in charge. 

When, however, catheterization becomes absolutely necessary, the 
genitalia having been first exposed and bathed with a bichlorid or boric 
solution, a freshly boiled glass catheter should be introduced by carefully 
disinfected fingers; or, better still, it should be grasped with a piece 
of freshly boiled cotton, so as to prevent its coming in contact with the 
fingers at all. At the present day, to catheterize a woman under a sheet 
or by the sense of touch is not justifiable. If repeated catheterization 
becomes necessary, 5-grain tablets of hexamethylenamin should be ad¬ 
ministered four times daily as a prophylactic measure against cystitis. 

Boivels .—In view of the sluggishness of the bowels in the puerperium, 
a mild cathartic should be administered on the morning of the third 
day, unless they have previously been evacuated spontaneously. For 
this purpose I generally employ an ounce of castor oil, or an ounce of 
Rochelle salts in a small quantity of water. 

After the preliminary cathartic, the bowels should be moved once 
daily. If a spontaneous action does not occur, the administration of the 
fluid extract of cascara at bedtime, in 20- to 60-minim doses, or 1 or 2 
drams of the aromatic elixir, according to the susceptibility of the pa¬ 
tient, is indicated. Sometimes a pill containing aloin, belladonna, and 
strychnin, or 1 to 2 teaspoonfuls of compound licorice powder, prove 
more satisfactory. 

Care of the Nipples .—Details concerning the care of the nipples will 
be given in the next chapter, but the physician should be careful to im¬ 
press upon the nurse the necessity of observing aseptic precautions in 
dealing with them; and she should be directed to report immediately the 
appearance of fissures, as their proper treatment will usually prevent 
mammary infection and the consequent danger of mastitis. 

Time for Getting Up .—It is a time-honored custom to allow the 
puerperal woman to sit up on the tenth day. This rule, however, should 
not be slavishly followed, and every patient should be kept in bed until 
the fundus of the uterus has disappeared behind the symphysis pubis. 
This frequently occurs by the tenth day, occasionally a day or so earlier, 


384 


THE PUERPERIUM 


but very often not until some days later. Generally speaking, a two 
weeks’ rest in bed is not excessive. 

Kiistner advocated the practice of allowing the patient to get up on 
the third or fourth day after delivery, and stated that he had seen no 
ill consequences following it. Ilis suggestion was promulgated before 
the German Gynecological Congress in 1899, and has found many fol¬ 
lowers, especially in Germany. No doubt it is feasible in most cases, 
but it has yet to be demonstrated whether it subserves the best interests 
of the patient. It is interesting to note that a similar suggestion was 
made by Charles White of Manchester as early as 1773, and 100 years 
later by Goodell of Philadelphia. 

It is also advisable to give strict directions as to the length of time 
the patient should remain out of bed. I have found it a convenient rule 
to direct that she should sit lip for one hour on the first day, two hours 
on the second, and to increase the time by an hour each day until she is 
able to be up all the time. She should be kept in her room until the 
expiration of the third week, and allowed to move about on the floor 
on which she was confined during the fourth week. She should not be 
permitted to go downstairs until the expiration of this period, as it is a 
matter of experience that the average woman cannot be prevented from 
assuming the ordinary duties of her household after she has once gone 
downstairs. In hospital practice, normal ward patients are usually 
discharged by the end of the second week and immediately assume their 
household duties. Private patients, who live in the city in which the 
hospital is located, may be discharged at the same time, but they should 
be cautioned to spare themselves for the following two weeks, as in¬ 
dicated above. On the other hand, those who must travel any con¬ 
siderable distance to return to their homes, should remain in the hospital 
for a longer period. 

Reappearance of Menstruation .—If for any reason the woman does 
not suckle her child, the menstrual flow will probably return within eight 
weeks after labor. On the other hand, it is generally believed that 
the flow ordinarily does not appear as long as the child is suckled, or 
at least not until it is nearly a year old. My own experience has shown 
that such a belief is erroneous, and that a considerable proportion of 
women menstruate during lactation, and usually without ill effect upon 
the children. Moreover, Pinard stated that from 40 to 73 per cent, 
of all his patients menstruated within six months after the birth of the 
child, and that the function becomes reestablished later in multiparous 
than in primiparous women. Ehrenfest in 1915 arrived at somewhat 
similar conclusions, and stated that 51.3 per cent, of his patients 
menstruated within three months, and 71 per cent, within six months 
after delivery; while in 80 per cent, menstruation occurred before the 
cessation of lactation. 

Final Examination .—At the end of the third or the beginning of the 
fourth week the patient should be subjected to an internal examination, 
when the condition of the perineum, uterus, and appendages should be 
carefully investigated. In approximately one-third of all patients— 
Lynch states 41 per cent.—the uterus will be found displaced, when 


LITERATURE 


385 


its replacement and the introduction of a properly fitting pessary may 
lead to a prompt cure; whereas if the treatment be deferred until 
symptoms appear, the condition may not be relieved so readily. In 
other cases various abnormalities may be noted, which should be treated 
before the patient is discharged, and occasionally it may be necessary to 
warn her that operative procedures will be required in the future. If 
everything is perfectly normal, it is a great comfort to the patient to 
be assured of the fact; whereas if any abnormality is noted and the atten¬ 
tion of some responsible member of the family be directed to it, the physi¬ 
cian may save himself from censure if a subsequent examination be 
made by someone else. 

Even though everything was found in order at the latter part of the 
puerperium, it is a wise precaution to encourage the patient to return 
for reexamination six months or one year later. In this event, ab¬ 
normalities, which may have originated in the meantime, can be recog¬ 
nized and, if necessary, corrected, while the visit affords the physician 
an opportunity to observe the general effect of childbearing upon his 
patient, as well as to ascertain what influence it has exerted upon any 
complication from which the patient may have suffered during pregnancy 
or labor. For a number of years, I have insisted upon such a yearly 
return in the case of our ward patients, and I am convinced that the 
results obtained have amply repaid both the patients and the members 
of the staff for the time and trouble taken. 

LITERATURE 

f 

Alsberg. Die Infektion der weiblichen Harnwege, etc. Archiv f. Gyn., 1910, 
xc, 255-302. 

Buttner. Die Gestationsveranderungen der Uteringefasse. Archiv f. Gyn., 1911, 
xciv, 1-21. 

Couvelaire. De l’acetonurie transitoire du travail de l’accouchement. Annales 
de gyn. et d’obst., 1899, li, 353-367. 

Doderlein. Untersuchungen liber das Vorkommen von Spaltpilzen in den Lochien 
des Uterus und der Vagina, etc. Archiv f. Gyn., 1887, xxxi, 412-447. 

Das Scheidensekret. Leipzig, 1892. 

Ehrenfest. The Reappearance of Menstruation After Childbirth. Am. Jour. 
Obst., 1915, lxxvii, 577-599. 

Friedlander. Physiol.-anat. Untersuchungen iiber den Uterus. Leipzig, 1870. 
Fritsch. Die puerperale Pulsverlangsamung. Archiv f. Gyn., 18/5, viii, 383-390. 
Gassner. Ueber die Veranderungen des Korpergewichtes bei Schwangeren, 
Gebarenden u. Wochnerinnen. Monatsschr. f. Geburtskunde, 1862, xv, 1-68. 
Goodall. The Involution of the Puerperal Uterus. Studies from the Royal 
Victoria Hospital, 1910, ii, No. 3. 

Goodell. Obst. J. Great Brit, and Ireland, 1875, No. 16. 

Heil. Untersuchungen iiber die Korpergewichtsverhaltnisse noxmaler Wochner¬ 
innen. Archiv f. Gvn., 1896, li, 18-32. 

Giebt es eine physiologische Pulsverlangsamung im Wochenbette? Archiv f. 
Gyn., 1898, liv, 265-280. 

Hinselmann. Die angebliche, physiologische Schwangerschaftsthrombose, etc. 

Zeitschr. f. Geb. u. Gyn., 1913, lxxiii, 146-222. 

Hofbauer. Zur Physiologie des Puerperiums. Monatsschr. f. Geb. u. Gyn., 1897, 
v, Erganzungsheft, 52-57. 


386 


THE PUERPERIUM 


Klemmer. Untersuchungen liber den Stoffweclisel der Wochnerinnen und die 
zweckmassigste Diat derselben. Winckel’s Berichte und Arbeiten, 1876, ii, 
155-186. 

Kronig. Bakteriologie des Genitalkanales der seliwangeren, kreissenden und 
puerperalen Frau. Leipzig, 1897, 54-64 und 196-201. 

Beitrag zum anat. Verhalten der Schleimhaut der Cervix und des Uterus wahrend 
der Schwangerscliaft und im Friivvochenbett. Archiv f. Gyn., 1901, lxiii, 
26-38. 

Kundrat und Engelmann. Untersuchungen iiber die Uterusschleimliaut. Strieker’s 
med. Jahrb., 1873. 

Kustner. 1st einer gesunden Wochnerin eine protrahirte Bettruhe denilieh? Yerh. 
der deutschen Gesellscli. f. Gyn., 1899, viii, 525-535. 

Leopold. Studien liber die Uterusschleimhaut, etc. Archiv f. Gyn., 1878, xi 
and xii. 

Little. Bacteriology of the Puerperal Uterus. Am. Jour. Obst., 1905, lii, 815- 
847. 

The Albuminuria of Pregnancy, etc. Am. Jour, of Obst., 1904, 1, 321-336. 

Lohlein. Ueber das Verhalten des Herzens bei Seliwangeren und Wochnerinnen. 
Berliner Zeitschr. f. Geb. u. Frauenkr., 1876, i, 482-516. 

Longridge. Excretion of Creatinin in the Lying-in Woman. Jour. Obst. and Gyn. 
Brit. Emp., 1908, xiii, 420-429. 

The Blood-tight Uterus and Its Intluence on Involution. Brit. Med. Jour., 1909, 
ii, 1459-1462. 

Lynch. The Bradycardia of the Puerperium. Surg. Gyn. and Obst., 1811, xii, 
441-451. 

Retroversions of the Uterus following Delivery. Am. J. Obst. & Gyn., 1922, 
iv, 362-371. 

McCann and Turner. On the Occurrence of Sugar in the Urine during the 
Puerperal State. Trans. London Obst. Soc., 1892, xxxiv, 473-490. 

Moore. Creatinin and Creatin Output during the Puerperium. J. Am. Med. Assoc., 
1915, lxv, 1613-1615. 

Murlin. Protein Metabolism of Normal Pregnancy. Surg. Gyn. & Obst., 1913, 
xvi, 43-53. 

Ney. Ueber das Vorkommen von Zucker im Harne der Scnwangeren, etc. Archiv 
f. Gyn., 1889, xxxv, 239-256. 

Novak u. Jetter. Beitrag zur Kenntniss der puerperalen Bradycardia. Monats- 
schr. f. Geb. u. Gyn., 1910, xxxii, 531-550. 

Olshausen. Ueber die Pulsverlangsamung im Wochenbette und ihre Ursache. 
Zentralbl. f. Gyn., 1881, v, 49-53. 

Pankow. Graviditats-sclerosen der Uterus- und Ovarialgefasse. Archiv f. Gyn., 
1906, lxxx, 271-282. 

Pinard. La menstruation dans ses rapports avec ovulation, etc. Annales de gyn. 
et d’obst., 1909, N. S. vi, 721-733. 

Sanger. Die Riickbildung der Muscularis des puerperalen Uterus. Beitrage zur 
path. Anat. und klin. Med., von Wagner’s Schiilern, 1887, 134. 

Scholten. Ueber puerperale Acetonurie. Beitrage zur Geb. u. Gyn., 1900, iii, 
439-451. 

Schroeder. Lehrbuch der Geburtsliiilfe, XIII. Aufl., 1889, 268. 

Schwartz. The Pathology of Chronic Metritis and Chronic Subinvolution. Am. 
J. Obst., 1919, lxxix, 63-94. 

Slemons. Involution of the Uterus and Its Effect upon the Nitrogen Output 
of the Urine. Bull. Johns Hopkins Hosp., 1914, xxi, 195-200. 

Varnier. Du ralentissement du pouls pendant les suites des couches. Annales 
de gyn. et d’obst., 1899, li, 30-47. 


LITERATURE 


387 


Webster. The Anatomy of the Female Pelvis during the Puerperium. Researches 
in Female Pelvic Anatomy, Edinburgh, 1892, 1-55. 

White. A Treatise on the Management of Pregnant and Lying-in Women. Lon¬ 
don, 1776. 

Wormser. Die Regeneration der Uterusschleimhaut nach der Geburt. Archiv f. 
Gyn., 1903, lxix, 449-579. 


CHAPTER XVII 


THE NEWLY BORN CHILD 


In this chapter will be considered only those conditions which are of 
direct practical interest to the obstetrician, who is referred to the 
standard works upon pediatrics for information concerning the special 
physiology and pathology of the infant. 

Normally the newly horn child begins to cry almost immediately 
after its exit from the vulva. This act indicates the establishment of 
respiration, which is accompanied by important modifications in the 
circulatory system. The mode of production of the first breath has 
given rise to much speculation. Among the many hypotheses that of 
Warnekros deserves consideration. In his X-ray studies of the process 
of labor, he noted an almost conical compression of the thorax during 
the second stage, and suggested that the expansion which must inevitably 
follow the delivery of the shoulders would afford a plausible explanation 
for the first inspiratory movement. 

Circulatory Changes. —As soon as the lungs begin to function, the 
blood which is brought by the inferior vena cava to the right auricle no 
longer passes through the foramen ovale, but makes its way directly 
through the right ventricle, whence it is carried to the lungs by means 
of the pulmonary arteries. Coincident with the establishment of the 
pulmonary circulation, there ensues a marked increase in the pressure in 
the left auricle. This in turn brings about the closure of the valve of 
the foramen ovale, which after a few months fuses with the periphery of 
the opening. At the same time the blood ceases to flow through the 
ductus Botalli into the aorta, and the canal itself gradually becomes 
obliterated. According to Strassmann, the primary cause for this change 
is to be found in the fact that the ductus traverses the wall of the aorta 
in an oblique direction, so that, as soon as the pressure in the aortic 
arch is increased, its wall acts as a valve and in this way occludes the 
distal end. 

The circulation through the umbilical arteries normally ceases in 
from 5 to 15 minutes after birth, pulsation disappearing first at the 
maternal end of the cord. This is brought about by the contraction of 
the thick muscular walls, which practically obliterate the lumina of the 
arteries. It is usually stated that after the establishment of the pulmo¬ 
nary circulation the general arterial pressure is diminished to such an 
extent that it is insufficient to force the blood through them. The investi¬ 
gations of Ahlefeld have shown that this is not the case, and would 
rather indicate that the contraction of the arteries is brought about by 
the stimulation resulting from the cooling of the cord immediately after 

388 






CARE OF THE UMBILICAL CORD 


389 


birth. That this explanation is correct is demonstrated by the fact that 
the circulation can be reestablished by immersing the child in a warm 
bath. 

This point is of practical importance in view of the fact that occa¬ 
sionally, when the cord has not been ligated sufficiently tightly, secondary 
hemorrhage occurs from its foetal end after the child has been placed in 
a warm bed. To guard against such an occurrence the cord should be 
reinspected before the physician leaves the patient. 

The child passes urine almost immediately after birth, and fre¬ 
quently while in the act of being born. In a considerable number of 
cases a certain amount of meconium is also discharged. As a result of 
the cooling of the surface of the child on coming into the world, its 
temperature becomes reduced by a few degrees, which, however, are 
promptly regained after it has been bathed and placed in a warm bed. 
For the first few days of life the temperature is in very unstable equilib¬ 
rium, and a very slight cause may give rise to a considerable elevation. 

Care of the Umbilical Cord. —As has already been said, the umbilical 
cord should not be ligated until it has ceased to pulsate, unless there is 
some urgent reason to the contrary. Two ligatures of sterilized bobbin 
should be placed about it and tightly tied, one about 2 centimeters from 
the surface of the abdomen, and the other about the same distance beyond 
the first, the cord being then cut between them with a pair of sterile 
scissors. 

Owing to the absence of circulation, what is left of the cord under¬ 
goes mummification, and gradually a line of demarcation appears just 
beyond the skin surface of the abdomen, until in a few days the stump 
sloughs off, leaving behind a small, granulating wound, which, after 
healing, forms the umbilicus. 

This separation usually takes place within the first ten days after 
birth, but it is not unusual for it to require a longer time, and occasion- 
ally several weeks may elapse before it occurs. In the very rare in¬ 
stances in which the stump is still adherent at the end of the puerperium, 
it may become necessary to clip it off with a pair of scissors. 

Formerly the care of the cord was considered a very trivial matter, 
and the midwife, as a rule, would wrap it in a piece of greased or singed 
linen, after which little or no attention was paid to it. This practice, 
however, and the total neglect of aseptic precautions frequently resulted 
in an infection which was transmitted through the umbilical vessels, so 
that in times past large numbers of children perished from so-called 
“puerperal fever,” as well as from tetanus neonatorum. Even now, 
when the necessity for proper treatment is generally recognized, umbil¬ 
ical infections are not unknown. 

Attention was redirected to such conditions by Eross in 1891, who 
stated that a great part of the rises in temperature occurring in young 
infants is due to umbilical infections. Keller, after studying the vital 
statistics of Berlin for the years 1904 and 1905, concludes that at least 
20 per cent, of all deaths during the first weeks of life are due to this 
cause. 

Usually these umbilical infections indicate gross lack of care, but 


390 


THE NEWLY BORN CHILD 


occasionally they occur in spite of every precaution. Thus, within one 
week four babies in my service died from general streptococcus per¬ 
itonitis, which could be traced to an infectious process in the umbilical 
vessels. This epidemic occurred at a time when especial interest was 
being taken in the care of the cord, and when not a single case of puer¬ 
peral infection had been in the ward for weeks, so that the only cause 
which could be discovered for it was an infected finger in the mother 
of one of the children. As the umbilical stump in these cases presented 
no outward sign of infection, the conditions would have escaped detec¬ 
tion had autopsy not been performed. Accordingly, it may be stated as 
a general rule that, whenever children die without any appreciable cause 
within two weeks after birth, such an infection should be suspected, 
and the examination of the intra-abdominal portion of the umbilical 
vessels will usually show that they are filled with purulent thrombi, in 
which pyogenic microorganisms can be demonstrated, and which have 
given rise either to a general infection or a peritonitis. In view, there¬ 
fore, of the not inconsiderable danger of infection from this source, 
strict aseptic precautions should be observed in caring for the cord. The 
reader is referred to Ploss’s work for interesting details concerning its 
treatment in various countries and by aboriginal peoples. 

After making the mother comfortable, the nurse should devote her 
attention to the child. After being anointed with vaseline or olive oil, 
it should be thoroughly washed with Castile soap and water, as experience 
has shown that the vernix caseosa is much more readily removed when 
some oleaginous substance is first employed. Or, it may be removed by 
means of cotton pledgets soaked in albolene, and the bath dispensed 
with. After the vernix caseosa has been removed, the stump of the cord 
should be thickly sprinkled with powdered boric acid and covered with 
a pad of sterile gauze, which should be held in place by narrow adhesive 
strips. If the child is doing well, this dressing need not be changed for 
some days unless it becomes moist or soiled. On removing it, the cord 
will usually be found to have become completely separated, otherwise 
a similar dressing should, be reapplied. I have obtained satisfactory 
results with this method of treatment, although in some cases it appears 
to prolong unduly the separation of the cord. Since 1906, I have 
employed the alcohol dressings recommended by Budberg. For this pur¬ 
pose the umbilical stump is wrapped in a small strip of sterile gauze 
soaked in 95 per cent, alcohol, after the excess has been allowed to drain 
off. Such dressings must be changed daily. 

After the cord has sloughed off, the granulating umbilicus should 
be covered by a sterile dressing, and the child should not receive a full 
bath until it has completely healed. During this period it should be 
bathed in the lap of the nurse, care being taken not to contaminate the 
umbilical dressings. 

Dr. W. M. Dabney, while an assistant in my service, made compara¬ 
tive observations in the hope of determining the best method of dealing 
with the cord. He treated several series of cases, respectively, with the 
following dressings: boric acid, salicylic acid, a mixture of salicylic acid 
and starch, and a wrapping of silver foil. So far as he could see, it 


CARE OF THE EYES 


391 


made no difference which method was employed, provided the dressings 
were sterile. In still another series of cases he applied an occlusive 
dressing of liquid celloidin, but found that in such circumstances thq 
cord was kept unduly moist, and separation was perceptibly delayed. 

The question as to the proper method of treating the cord has given 
rise to a great deal of discussion. Dickinson in 1899 in a paper en¬ 
titled, Is the Sloughing Process at the Child’s Navel Consistent with 
Asepsis in Child-bed? answered the question in the negative, and in 
1916 reaffirmed his belief. He recommended that the cord be completely 
excised where it joins the abdomen, its vessels ligated, and the wound 
closed by sutures. Possibly this may be the ideal method of treatment, 
but it is a question whether it is advisable in private practice, as it is 
probable that, should the child die within a few weeks after such a 
procedure, the physician would be severely criticized by members of the 
family who have become accustomed to the time-honored treatment. 

Martin recommended that the cord be ligated close to the abdomen 
and cut through with a pair of red-hot scissors. Porak and others advo¬ 
cate its compression by powerful forceps, as in angiotripsy, while Ziegler 
has devised an ingenious rubber clamp for the purpose. Rachmanow, 
on the other hand, believes that all such precautions are useless, and 
reported that in 9,000 out of 10,000 consecutive children delivered under 
his care he had simply cut the cord, after it had ceased to pulsate, and 
in not a single instance did serious hemorrhage occur, notwithstanding 
the fact that no ligatures were used. Such results, however, are con¬ 
trary to my experience, as I have repeatedly observed profuse hemor¬ 
rhage after the cord had been carefully ligated. 

Care of the Eyes.— In view of the frequency with which the eyes of 
the newly born child become infected when passing through the birth 
canal of women suffering from gonorrhea, Crede in 1884 introduced 
the practice of instilling into each eye immediately after birth one drop 
of a 1-per-cent, solution of nitrate of silver, which was afterward washed 
out with salt solution. This procedure has led to a marked decrease in 
the frequency of gonorrheal ophthalmia and the cases of blindness result¬ 
ing from it, and should be followed as a matter of routine. Even in 
my private work I habitually employ Crede’s method, as the development 
of ophthalmia in several babies treated v ith boric acid solution taught 
me that gonorrhea may be present where least expected. 

The prophylactic value of silver nitrate was strikingly demonstrated 
by Haab, whose statistics showed that its employment in hospital prac¬ 
tice had reduced the frequency of ophthalmia neonatorum from 9 to 1 
per cent., while the statistics from many hospitals show an incidence of 
only 1/5 to 1/10 of 1 per cent. If, however, the disease should appear 
in spite of the precautions taken, it should be promptly and vigorously 
treated, inasmuch as when neglected it almost invariably leads to cloud¬ 
ing of the cornea and often to complete blindness. Cohn estimated in 
1876 that 30 per cent, of the patients in the blind asylums of Germany, 
Austria, Holland, and Switzerland owed their trouble to ophthalmia 
neonatorum. Twenty years later these figures had become reduced to 
19 per cent.; while Crede-Horder in 1912 reported a further diminution 


392 


THE NEWLY BORN CHILD 


to 12.39 per cent. Dr. J. J. Carroll stated that 30 per cent, of the 
inmates of the Maryland School for the Blind in 1909 owed their 
blindness to the same cause, and that its incidence had increased rather 
than decreased during the previous twenty years. This means that our 
results are much worse than in Germany, and that the average prac¬ 
titioner and midwife have failed to appreciate the prophylactic value of 
Crede’s method, and makes pertinent the inquiry as to the advisability of 
legislation making the use of silver nitrate compulsory in all cases. 

In very rare instances the process may be thoroughly established at 
the time of birth—the so-called intra-uterine ophthalmia. In such cases 
the infection developed while the child was still in utero, and Stephen¬ 
son states that it may even occur without premature rupture of the 
membranes, having been noted in children born in a “caul.” 

Zweifel in 1900 advocated substituting a 1-per-cent, solution of silver 
acetate for the nitrate, and reports that, in a series of 5,222 children so 
treated, ophthalmia was observed in only 0.23 of 1 per cent. The 
employment of protargol, argyrol, sophol, and various other preparations 
of silver has been suggested, but experience has shown that they give no 
better results than silver nitrate. Care should be taken that only fresh 
solutions are employed, as they rapidly deteriorate on keeping, especially 
when exposed to the light. 

Stools and Urine.—For the first few days after birth the intestinal 
contents are represented by a brownish or brownish-green, soft material 
—the meconium. It is made up of cast-off epithelial cells from various 
portions of the intestinal tract, a few epidermal cells and lanugo hairs 
which have been swallowed with the amniotic fluid. Its peculiar color 
is due to the presence of bile pigments. During pregnancy and for a 
few hours after birth the intestinal contents are sterile, but bacteria soon 
gain access to them and are afterward present throughout life. 

After the third or fourth day, with the establishment of the mam¬ 
mary secretion, the meconium disappears, and its place is taken by 
feces, which are light yellow in color, homogenous in consistence, and 
possess a characteristic odor. For the first few days the stools are not 
formed, but after a short time they take on the characteristic cylindrical 
shape. The bowels, as a rule, move twice daily, but a single large dejec¬ 
tion is sufficient. 

The physician should make it a rule to inspect the stools at each 
visit, and instruct the nurse to save a napkin in anticipation of his 
arrival, as in this way important information may be gained concerning 
the digestion of the child. 

The child usually urinates almost immediately after birth, and con¬ 
tinues to do so at frequent intervals for the first few months of its life. 
The physician should impress upon mother and nurse the necessity of 
attempting to train the child to regular habits as to urination and defe¬ 
cation, and it is surprising how soon these may be formed if proper care 
is taken. For this purpose the napkins should be changed before each 
feeding, and after the first few weeks the child should be held over a 
small chamber at these times. It should also be encouraged to defecate 
at regular intervals. To accomplish this, it should be laid upon the bed 


ICTERUS 


393 


at the same hour each day with a napkin under its buttocks, and its ab¬ 
domen stroked along the course of the colon. 

Icterus.-—Not infrequently on the third or fourth day after birth, 
the skin and conjunctivae of the child take on a yellowish hue, which 
may vary from a hardly visible discoloration to an intense jaundice. 
Kehrer concluded that-icterus occurred in 75 per cent, of all children, 
and, although this estimate is certainly too high, there is no doubt that 
it is very common. According to Hofmeier, the condition is hematog¬ 
enous in origin, and is due to the breaking down of large numbers 
of red corpuscles soon after birth. Its mode of production has given 
rise to considerable discussion, which was well summarized by Linzen- 
meier and Lilienthal, in 1922, who believe that it is hepatogenous in 
origin, and is due to the fact that the liver has not fully assumed its 
postnatal functions. Ordinarily it possesses no clinical significance, 
and passes off in a few days without treatment. 

Initial Loss of Weight .—Owing to the fact that the child receives 
little or no nutriment, and at the same time casts off considerable 
quantities of urine, feces, and sweat, it progressively loses weight for 
the first three or four days of its life, the total loss usually aggregating 
250 grams (8 ounces). If the child is nourished properly, this is 
usually regained by the end of the tenth day, after which the weight 
should increase steadily at the rate of about 25 grams (6 drams) a 
day for the first few months, so that it becomes doubled by the time 
the child is five months of age. 

The initial loss is usually much greater when the child is excessively 
large, as well as in 
premature infants 
and those who re¬ 
ceive an insufficient 
supply of food. 

Anatomy of the 
Breasts and Lacta¬ 
tion. — Each breast 
is made up of from 
15 to 24 lobes, 
which are arranged 
more or less radial¬ 
ly, and separated 
from one another by a varying amount of fat, to which the size 
and shape of the organ is in great part due. Each lobe consists of 
several lobules, which in turn are made up of large numbers of acini. 
These last are composed of a single layer of epithelium, beneath which 
is a small amount of connective tissue richly supplied with capillaiies. 
Every lobule is provided with a small duct, which, meeting others, 
unites to form a single larger canal for each lobe. These so-called 
lactiferous ducts make their way to the nipple and open separately 
upon its surface, where they may be distinguished as minute isolated 

orifices. . . 

The acini represent the functioning portion of the breasts, and it is 



Fig. 329. —Lactating Breast (Zeiss, DD-4). 














394 


THE NEWLY BORN CHILD 




from their epithelium that the various constituents of the milk an 
formed. This fact was first demonstrated by Heidenhain. 

We have already referred to the changes occurring in the breasts 
during pregnancy, and their condition remains much the same for the 
first two days after labor. At this time they do not contain milk, bui 
a small amount of colostrum can be expressed from the nipples. This 
is a thin, yellowish fluid, which owes its color to the presence of a pig¬ 
ment which is soluble in ether and, according to Kiihne, is analogous 
to the coloring matter contained in the cells of the corpus luteum. 

When examined under the microscope, colostrum is seen to consist 
of a fluid in which are suspended numerous round bodies, 0.001 to 
0.025 millimeter in diameter—the so-called colostrum corpuscles — 
which represent cast-off epithelial cells which have undergone fatty de¬ 
generation. The fluid portion is a transudate which consists in great 
part of serum albumin and coagulates on heating. Colostrum con- 


Fig. 330. —Human Colostrum 
(Zeiss, DD-4). 


Fig. 331. —Human Milk (Zeiss, DD-4), 


tains more proteid material and salts, but less fat, than normal milk; 
while its sugar content is about the same. 

It is generally stated that it possesses but slight nutritive properties 
and that its chief function is to act as a mild cathartic. Jaschke and 
Ludwig, on the contrary, hold that children receiving it in considerable 
quantities suffer a much slighter initial loss of weight than usual. 
They also believe that the serum albumin which it contains is taken 
up without change by the epithelium of the digestive tract. Lewis and 
Wells consider that its chief value consists in its englobulin content, 
which can pass directly into the blood and apparently carries with it 
certain protective antibodies in which the child is deficient. For this 
reason they hold that it is most desirable that every new-born infant 
should receive its full ration of colostrum, whereby its immunity to 
various infections is increased. 

Millc .—On the third or fourth day after labor and occasionally on 
the second, the breasts suddenly become larger, firmer, and more pain- 














ANATOMY OF THE BREASTS AND LACTATION 


395 


ful. This indicates the establishment of the lacteal secretion, and 
on pressure a small amount of bluish-white fluid—the milk —will exude 
from the nipples. Coincident with these changes, the patient experi¬ 
ences more or less lassitude, and may suffer from headache. At the 
same time she has throbbing pains in the breasts, which may extend 
into the axillae, and the pulse becomes slightly accelerated. There is 
rarely any elevation of temperature. It was formerly believed that the 
establishment of the milk flow was associated with marked constitutional 
disturbances, which were regarded as manifestations of the so-called 
milk fever. As has already been said this is very exceptional, and 
usually a rise of temperature at this time is indicative of infection. 

Mother’s milk is usually bluish-white in color, though it sometimes 
has a yellowish tinge. It is slightly alkaline in reaction, and has a 
specific gravity of from 1.028 to 1.034. Under the microscope it ap¬ 
pears as a clear fluid in which are suspended large numbers of small 
round bodies, 0.008 millimeter in diameter—the so-called milk cor¬ 
puscles. These consist of minute drops of fat surrounded by a mem¬ 
brane. Chemical examination shows that they are made up of the 
triglycerides of olein, palmatin, and stearin. The fluid portion of the 
milk is a transudate, and consists of protein material, milk sugar, salts, 
and water. Milk, therefore, represents an emulsion of fine fat droplets 
in a fluid medium. 

The protein material in milk serum consists of one-third casein 
and two-thirds lactalbumin, which are direct metabolic products of 
the mammary epithelium, and differ from serum albumin in that they 
do not coagulate on heating. The fat and lactose, or milk sugar, are 
also products of the epithelial cells. The milk serum contains a con¬ 
siderable amount of mineral matter, one-half of which, according to the 
investigations of Holt, consists of calcium phosphate and potassium 
carbonate, while the remainder is made up of sodium chlorid, potas¬ 
sium chlorid, potassium sulphate, magnesium carbonate, and minute 
quantities of several other salts, including iron. 

The average composition of milk is as follows: Proteids, 1 to 2 per 
cent.; fats, 3 to 4 per cent.; sugar, 6 to 7 per cent.; salts, 0.1 to 0.2 
per cent., the ^est being water. According to Holt, the average com¬ 
position of 17 twenty-four hour specimens of mature milk was as 
follows: Proteids, 1.15; fat, 3.26; sugar, 7.5, and ash, 0.206 per cent., 
respectively; while in the so-called transitional period—from the end 
of the first to the fourth week—the proteid and fat content is consid¬ 
erably greater—1.56 and 4.37 per cent., respectively. Milk also contains 
a not inconsiderable number of bacteria, which, according to the re¬ 
searches of Kostlin, are derived from the terminal ends of the lac¬ 
tiferous ducts and the surface of the nipples; it is questionable whether 
they are present in the deeper portions of the breast. 

Nutritious mothePs milk varies markedly in its composition, not 
only in different individuals, but also in the same individual at various 
times. It is not unusual to find that the milk of one woman, which 
agrees perfectly with her own child, will prove indigestible when given 
to the healthy child of another woman. The variation in the compo- 


396 


THE NEWLY BORN CHILD 


sition of the milk of the same woman at different times is dependent 
upon various factors, principally the diet, the amount of exercise, and 
the mental condition. The quantity of milk varies to a large extent 
with the amount of fluid ingested by the patient, and a diet rich in 
cow’s milk conduces to increased mammary activity. 

There are large numbers of preparations in the market which are 
known as galadagogues, and are vaunted as increasing the amount of 
milk; but whatever virtue they may possess is due in great part to the 
quantity of fluid taken with them. Exercise in the open air also in¬ 
creases the milk flow, and it is frequently observed that a woman who 
has hut a small quantity, so long as she is confined to her room, will 
secrete an abundant supply as soon as she begins to take outdoor 
exercise. 

The quality of the milk is likewise dependent in great part upon 
the food and the amount of exercise taken by the mother. It is a 
matter of experience that a diet rich in proteids increases the ratio 
of the fats, while excessive exercise diminishes the amount of protein 
material. Marked alterations in the quality and quantity of protein 
frequently result from nervous and mental influences, and it is not 
unusual for some profound emotion to lead to almost complete sup¬ 
pression of the lacteal secretion, or to so change its quality as to render 
it temporarily unfit for the use of the infant. Certain drugs also 
exert a marked influence upon the milk flow, and it is well-known that 
the use of belladonna or atropin markedly diminishes it. Many sub¬ 
stances ingested by the mother may be transmitted through the milk, 
and thus exert their physiological influence upon the child. This is 
particularly true of the various cathartics and alcoholic liquors. 

It is generally believed that the occurrence of menstruation, or the 
onset of another pregnancy during lactation, exerts a very deleterious 
effect upon the quality of the milk, in some cases rendering it neces¬ 
sary to wean the child. "When it is remembered how large a proportion 
of women menstruate while suckling, and how often the first indication 
of the occurrence of pregnancy in a nursing mother consists in the 
perception of foetal movements, it is apparent that the deleterious effect 
of such occurrences is greatly overestimated. 

pursing.—The ideal food for the newly born child is the milk of its 
mother, and, unless lactation be contra-indicated by some physical 
defect, it is the physician’s duty to insist that every woman should at 
least attempt to suckle her child. In many instances where the supply 
of milk at first appears insufficient, it becomes increased in amount 
if suckling be persisted in. The act itself also exerts a beneficial influ¬ 
ence upon the involution of the uterus, as it is well-known that the 
repeated irritation of the nipples results in reflex stimulation of the 
uterus, and Temesvary has further proved by actual measurement that 
involution occurs more rapidly in nursing women. This fact should be 
urged upon those who are unwilling to nurse their children, and it fre¬ 
quently happens that, although they may have commenced it from 
selfish motives, they will continue it as long as is necessary. 

Unless it be otherwise arranged, the physician who conducts the 


JRSING 


397 


labor should hold himself responsible for the well-being of the child 
during the first few weeks of its life, and should not limit his attentions 
to the mother. He should accordingly give minute directions as to the 
way in which it should be fed, and see that they are accurately carried 
out. 

Frequency of Feeding — As the nutritive properties of colostrum are 
very limited, the child should be put to the breast only three times a 
day until the milk flow becomes established, but after that time it 
should be fed at intervals of three or four hours. Definite hours should 
be set for each feeding, and, if necessary, the child should be awakened 
from a sound sleep at stated times to take its nourishment, for only 
by this means can its habits be made regular. I do not consider that 
a nurse has fulfilled her whole duty unless she leaves the patient with a 
child properly trained in the matter of taking its food. 

A definite hour should be arranged for the child’s bath, which should 
be taken as a starting-point in arranging the schedule for feeding. 
Ordinarily the most convenient time is between 9 and 10 a. m. If the 


former hour be chosen, the first feeding should be at G a. m., and the 
next immediately after the bath. After bath the baby should be 
allowed to sleep as long as it will, which will usually be several hours, 
after which it should be given nourishment at fixed intervals. By this 
arrangement it will receive six to seven feedings during the twenty- 
four hours, according as the three or four-hour schedule is followed. 
In any event, the last feeding should be timed for the usual bedtime of 
the parents, and only one feeding should be given during the night— 
that is, between 11 p. m. and G or 7 a. m.— and frequently the child 
can be trained to sleep the entire night without awakening. This, 
however, can only be accomplished by feeding it at regular intervals 
during the day, so as to insure that it receives the proper amount of 
nutriment in the twenty-four hours. 

Just before each feeding the n 
child encouraged to urinate, but as 
it should be placed in bed and not d ioe ill ucu. 


Uv. 


L Oill/UlU 1 nM. MVv 11 i i V/ m V. v i 


to sleep at its mother’s breast, nor should it be rocked or fondled after 
feeding. If these regulations be persisted in, the child will usually go 
to sleep within a few minutes after being put to bed, and if it wakes 
before the next feeding is due it will rer ' ”ie+ The importance 
of following these directions cannot be ov 1 by 

rigid adherence to such details that the 
habits, and its care prevented from becoming 


con¬ 


cerned. 

After the fourth or fifth week, unless the child is placed upon a 
four-hour schedule, one of the breast feedings may be replaced by 
a bottle, even though the milk supply is adequate. By so doing the 
tedium of nursing is greatly reduced, and many a woman is willing 
to suckle a child which she would otherwise wean. When a mother 
is obliged to return home every few hours r 'sc *■ ;• hild, it is 
apparent that her time is so broken in upon impossible 


398 


THE NEWLY BORN CHILD 


for her to obtain any real relaxation; whereas if a single bottle be inter¬ 
polated between any two feedings a long free space will be afforded. 

Duration of Feeding .—Definite rules cannot be given concerning 
the proper length of each feeding, as this point is dependent upon 
several factors—the quantity of milk, the readiness with which it can 
be obtained from the breast, and the avidity with which the child 
nurses. Generally speaking, it is advisable to allow the child to remain 
at the breast for ten minutes at first, and to lengthen or decrease 
the time according to circumstances, three or four minutes being suf¬ 
ficient for. some children, while fifteen or twenty minutes will be re¬ 
quired by others. There is so universal a tendency toward overfeeding 
that at first it is better to err in giving too little rather than too much 
milk. Crying is not always a symptom of hunger, but much more 
frequently indicates indigestion, resulting from an overloaded stomach. 
A child which is receiving the proper amount of nourishment should 
not spit up its food, should increase steadily in weight, and should 
have normal yellow homogeneous passages. The occurrence of regurgi¬ 
tation, or the presence of curds in the stools, is a sure sign that it is 
being nursed too long. On the other hand, loss of weight, associated 
with normal stools and the absence of reguigitation, indicates insuf¬ 
ficient feeding. 

The child should be weighed twice a week, upon a fairly accurate 
pair of scales, and its actions inspected daily by the physician. As has 
already been said, it should regain its birth weight by the end of the 
tenth day, and from then on it should gain regularly 25 grams a day, 
or, roughly speaking, 5 ounces a week. After the first few months 
the increase is more gradual, the average child doubling its weight at 
the fifth and trebling it at the fifteenth month. 

Care of the Breasts.—Before and after each feeding the nipples 
should be carefully washed with a boric acid solution, so as to avoid the 
possibility of bacteria being ground into them during suckling. In 
many cases, particularly if preliminary precautions have not been 
taken to prepare them, the nipples become very sore during the first 
few days of nursing, and little cracks or fissures appear upon them. 
These are extremely painful to the mother, and in some cases render 
the act of suckling agonizing. In addition to the suffering which they 
cause, they are also a source of considerable danger, as it is through 
them that bacteria gain access to the interior of ihe breast. The 
nurse should therefore instructed to be on the lookout for them, 
and to notify the physician of their appearance, as prompt treatment 
will usually lead to their speedy cure. On the other hand, neglect of 
these premonitory signs is frequently followed by a mammary abscess, 
for the occurrence of which the physician and nurse are usually more 
or less justly blamed. 

The fact that large numbers of remedies are recommended for the 
cure of fissured nipples is abundant evidence that they are not always 
readily relieved. They are best treated by rest, and if the infant could 
be kept from the breast for twenty-four hours they would heal without 
further treatment. As this is out of the question, some other means 


CARE OF THE BREASTS 


399 


of securing rest must be adopted, and this is best attained by the use 
of a so-called English nipple shield, or one of the curved variety de¬ 
vised by Slemons. Many women claim that they are unable to use such 
a contrivance, but the difficulty is usually due to the fact that the holes 
in the rubber nipple are too small, and if they are enlarged by passing 
a red-hot hairpin through them a quantity of milk sufficient for the 
child can usually be obtained without much difficulty. The application 
of compound tincture of benzoin to the fissures tends to hasten the 
healing, and in the intervals between the feedings the nipples should 
be covered by compresses soaked with boric acid solution. Particular 
attention should be devoted to the care of the shield, which should be 
boiled daily, and carefully washed after each feeding and kept in a 
vessel containing a saturated solution of boric acid. 

In rare cases the nipples may be so depressed below the surface of 
the breast as to render nursing out of the question. Here it is useless 
to attempt it, and steps should be promptly taken to arrest the mam¬ 
mary secretion. 

It was formerly taught that the child’s mouth should be scrupulously 
cleansed before each feeding by washing it out with a clean piece of 
linen dipped in boric acid solution, with the idea of diminishing the 
possibility of breast infection. Although it is known that bacteria are 
constantly present in the buccal cavity of infants, experience has shown 
that the practice is useless, as it has no effect upon the incidence of 
mammary infection, and has the disadvantage that it sometimes leads 
to infection of the child’s mouth. 

When the child dies, or if for any reason the physician feels that 
lactation is contra-indicated, steps should be taken to check lactation, 
or, as it is usually designated, "to dry up the breasts.” Formerly 
this was accomplished by a tedious and laborious process, which con¬ 
sisted in tightly bandaging the breasts, after having covered them with 
belladonna ointment. Within a few hours they became very engorged 
and painful, when the excess of milk was drawn off by means of a breast 
pump, after which the bandage was reapplied, and the process repeated 
as frequently as necessary, days or weeks often elapsing before the 
secretion was checked. The treatment was sometimes so painful that 
the patient complained that it was far worse than the labor itself. 

Some years ago, Dr. E. R. Lewis, of Westerly, R, I., told me that 
equally good results could be obtained in far less time merely by the 
administration of 20 grains of potassium act ,e every four hours. My 
investigations, however, have shown that the drug is without effect, and 
that Nature will take care of the entire process, if not aggravated by 
improper treatment. 

Since 1905 my practice has been to leave the breasts absolutely 
alone. Within twenty-four hours after the last nursing, or on the 
third day, if the child has not been suckled, the breasts become en¬ 
gorged, and sometimes quite painful. Rut if they are not touched, 
the swelling soon subsides, and the pain disappears within a few hours, 
after which the breasts gradually become smaller, and contain less and 

it the entire process is over by the end of the third day. 


400 


THE NEWLY BORN CHILD 


If the patient is nervous a placebo may be administered, or if the pain 
is severe a single hypodermic injection of morphia may be required, 
but further medication is not necessary. When the breasts are large 
and pendulous, they may be supported by a bandage, which, however, 
should not be sufficiently tight to exert pressure. It would accordingly 
appear that the methods formerly in vogue, and particularly the use of 
the breast pump and massage, defeated the very purpose for which they 
were employed, and really serve to stimulate the secretion of milk and 
subject the patient to great discomfort. 

My experience with the method, both in hospital and private prac¬ 
tice, has been so satisfactory that I can strongly recommend its adop¬ 
tion. Those who are interested in details concerning it are referred 
to the article by my former assistant, Henry J. Storrs. 

Artificial Feeding.—When the supply of mother's milk is defective, 
or when abnormalities of the nipples or constitutional diseases render 
nursing inadvisable, artificial feeding must be resorted to. Numerous 
so-called infant foods are advertised for this purpose, but most of them 
are very defective, so that for practical purposes cow's milk in some 
form is the only available substitute for the mothers milk. Unfortu¬ 
nately, however, it differs markedly from the latter in composition, and 
under the most favorable circumstances is only an imperfect substitute 
for it. It is usually slightly acid in reaction, and has a specific gravity 
of 1.029 to 1.033. Its average composition is: proteids, 4 per cent.; 
fats, 4 per cent.; sugar, 4.5 per cent., and salts, 0.7 per cent. It is 
apparent, therefore, that it contains less fat and sugar, and more pro¬ 
tein material and salts, than mother's milk, and consequently cannot 
be used in its natural form, but must first be modified in some way. 

If the child is healthy, satisfactory results are frequently obtained 
by diluting cow’s milk with various proportions of water and adding 
sugar. Such preparations contain approximately the normal amount 
of proteid material and sugar, but are lacking in fat. In hot weather 
the mixture should be pasteurized, but in cool weather this procedure 
is unnecessary. 

The space at our disposal is too limited to permit consideration of 
the many and complicated problems connected with artificial feed¬ 
ing, and the reader is referred to the various treatises upon Pediatrics 
for extended information. There are, nevertheless, two points upon 
which I must insist—namely, the capacity of the stomach and the 
necessity for training the child to regular habits, no matter what 
method of feeding is employed. It should be remembered that the 
stomach of the newly born child is very small, and that one ounce will 
fill it to repletion. That amount of fluid, therefore, should not be 
exceeded for the first few days, after which it should be increased 
gradually. The instructions as to the frequency and manner of feeding, 
which have already been given, apply equally well whether the child is 
fed at the breast or from the bottle, and too great stress cannot be laid 
upon their rigid observance. 


LITERATURE 


401 


LITERATURE 

Ahlfeld. Lehrbuch der Geburtshiilfe, II. Aufl., 1897, 179. 

Budberg. Die Beliandlung des Nabelschnurrestes. Zentralbl. f. Gyn., 1898, 
1288-1289. 

Carroll. Why Does Ophthalmia Neonatorum Continue to Cause so much Blind¬ 
ness? Maryland Med. Jour. Dec., 1909. 

Cohn. Ueber Verbreitung und Verhiitung der Augeneiterung der Neugeborenen. 
Berlin, 1896. 

Crede. Die Verhiitung der Augenentziindung bei Neugeborenen. Berlin, 1884. 
Crede-Horder. Hat die Blennorhoea neonatorum abgenommen? Zentralbl. f. 
Gyn., 1912, 1503-1506. 

Dickinson. Is a Sloughing Process at the Child’s Navel Consistent with Asepsis 
in Childbed? Amer. Jour. Obst., 1899, xl, 14-66. 

Immediate Complete Amputation of the Umbilical Cord. Trans. Am. Gyn. Soc., 
1916, xli, 713-717. 

Eross. Beobaclitungen an 1000 Neugeborenen liber Nabelerkrankungen, etc. 
Archiv f. Gyn., 1891, xli, 409-449. 

Haab. Die Mikrokokken der Blennorrhcea neonatorum. Festschrift zu Horde,r, 
Wiesbaden, 1881. 

Hofmeier. Die Gelbsucht der Neugeborenen. Zeitschr. f. Geb. u. Gyn., 1882, 
viii, 287-353. 

Holt, Courtney and Fales. A Chemical Study of Woman ’s Milk. Am. Jour. 
Dis. Child., 1915, Oct., 229. 

Jaschke and Ludwig. Zur Biologie des Colostrums. Zeitschr. f. Geb. u. Gyn., 
1915, 188-201. 

Kehrer. Studien iiber den Icterus neonatorum. Jahrbuch fur Padiatrik, 1871, 
ii, 71. 

Keller. Die Nabelinfektion, etc. Zeitschr. f. Geb. u. Gyn., 1906, lviii, 454-475. 
Kostlin. Beitrage zur Frage des Keimgehaltes der Frauenmilch. Archiv f. 
Gyn. s 1897, liii, 201-277. 

Lewis and Wells. The Function of the Colostrum. J. Am. Med. Assoc., 1922, 
lxxviii, 863-865. 

Linzenmeier and Lilienthal. Zur Frage des Icterus neonatorum. Zentralbl. 
f. Gyn., 1922, 1873-1883. 

Martin. Die Versorgung des Nabels der Neugeborenen. Zeitschr. f. Geb. u. 
Gyn., 1900, xlii, 593-596. 

Ploss. Das Weib in der Natur- und Volker-kunde. IV. Aufl., 1895, Bd. II, 
182-198. 

Porak. De 1’omphalotripsie. Annales de gyn. et d’obstet., 1900, liv, 112-113. 
Rachmanow. Methode der Nicht-unterbindung der Nabelschnur. Zentralbl. f. 
Gyn., 1914, 590-592. 

Stephenson. Ophthalmia Neonatorum. London, 1907. 

Storrs. Checking the Secretion of the Lactating Breast. Surg. Gyn. and Obst., 
1909, ix, 401-405. 

Strassmann. Anat. u. Physiol. Untersuchungen iiber den Blutkreislauf bei 
Neugeborenen. Archiv f. Gyn., 1894, xlv, 393-445. 

Der Verschluss des Ductus arteriosus. Beitrage zur Geb. u. Gyn., 1902, vi, 
98-117. 

Temesvary. The Connection between the Female Breasts and Genitalia. Jour. 

Obst. and Gyn. Brit. Emp., 1903, iii, 511-525. 

Warnekros. Schwangerschaft und Geburt im Roentgen-bilde. Miinchen, 1921. 
Zweifel. Die Verhiitung der Augeneiterung Neugeborenen. Zentralbl. f. Gyn., 
1900, xxv, 1361-1380. 


CHAPTER XVIII 


MULTIPLE PREGNANCY 

The uterus occasionally contains two or more embryos; thus, ac¬ 
cording to the number present, we have a twin, triplet, quadruplet, 
quintuplet, or sextuplet pregnancy. 

According to Badouin, only five credible instances of sextuplet preg¬ 
nancy have been recorded, and even several of them have been sub¬ 
jected to considerable criticism. On the whole, it may be said that 
reports of the birth of a greater number of children at a single labor 
are to be regarded as apocryphal, although many such are to be found 
in the older literature, the most remarkable being the Rhine legend, 
according to which the Countess Hagenau was delivered of 365 em¬ 
bryos at a single labor—manifestly an hydatidiform mole. 

Frequency.—Wappaeus found that more than one child was born 
in 1.17 per cent, of 20,000,000 cases of labor which he analyzed. The 
statistics of G. Veit, which were based upon 13,000,000 cases occurring 
in Prussia, showed that twins occurred once in 89, triplets once in 
7,910, and quadruplets once in 371,125 labors. According to Mira- 
beau, triplets occur more frequently—once in 6,500 cases. De Blecourt 
and Nijhoff, in 1904, reported a case of quintuplets, and stated that 
they found in the literature what appeared to be authentic histories 
of 28 additional cases. 

It would appear that multiple pregnancy is more common in cold 
than in warm climates. This statement is borne out by the statistics of 
Bertillon and Mirabeau, the latter stating that they occur once in 
41.8 labors in Russia, as compared with once in 113.6 labors in Spain. 
Gache found that they occur most frequently in Greece and least so 
in Peru, being noted once in 50 labors in the former, as compared to 
once in 170 in the latter country. According to Duncan, twin preg¬ 
nancy is noted most frequently in multiparae, especially between the 
twenty-fifth and twenty-ninth years. 

It has been estimated that in 63.1 per cent, of the cases only one, and 
in 36.9 per cent, both sexes are represented. Thus, in the 717,907 
observations collected by Nichols, both children were males in 234,497, 
both females in 219,312, and of different sexes in 264,098 cases. 

Etiology.—Certain individuals appear to be predisposed toward mul¬ 
tiple pregnancy, since it is not unusual for the same woman to give 
birth to twins or triplets upon several occasions. Thus Puech, upon 
analyzing 1,262 cases of pregnancy, found that 48 of the mothers 
had given birth to twins twice, 3 thrice, and 1 upon 4 occasions. In 
some instances, multiple pregnancy has been known to occur in all 

402 


ETIOLOGY 


403 


the females of a family throughout several generations. Mirabeau has 
pointed out that an hereditary tendency toward triplet pregnancies was 
recorded in 13 out of the 75 cases collected by him. This was par¬ 
ticularly marked in one family, in which the birth of triplets, not to 

mention twins, had occurred one or more times in live successive gen¬ 
erations. 

Less frequently, however, this tendency appears to come through 
the father, and reference is frequently made to the somewhat apocryphal 
case of the Russian peasant, Wasilef, who is reported to have had 87 
children by 2 wives, the first having had 4 quadruplet, 7 triplet, and 1G 
twin pregnancies; and the second 2 triplet and 6 twin pregnancies. 
Da\enport, in 1920, sifted the evidence in this regard, which was based 
upon his geneological tables, and holds that the hereditary influence is 
exerted almost as frequently through the father as through the mother, 
particularly in the case of single ovum twins. 

This was especially evident in couples who had 
twins in a first marriage, and then married 
again. In this event the hereditary tendency 
appeared to be transmitted almost as frequently 
by the man as by the woman, as the incidence 
of twins in second marriages was many times 
greater than in the average family. 

Twin pregnancy may result either from the 
fertilization of two separate ova or of a single 
ovum, the first giving rise to double, or fra¬ 
ternal, and the second to single-ovum, or 
identical, twins. In the former case the ova 
may come ^rom the . same ovary, or one from 
each ovary; while in the latter only a single 
ovum is concerned. Fraternal twins may or may 
not be of the same sex, and do not necessarily 

resemble one another more than other children of the same parents; 
while identical twins are necessarily of the same sex, and, if they reach 
maturity, resemble one another closely. Approximately speaking, one 
out of every five sets of twins belongs in the latter category; as out of 
1,159 instances of twin pregnancy analyzed by Ahlfeld, 979 were derived 
from two ova and 180 from one ovum; whereas, Prinzing in 1,887 cases 
found that the incidence of single ovum twins was 26.3 per cent. 

According to Hellin, Patellani, and Larger, multiple pregnancy 
should be regarded as a sign of atavistic reversion analogous to the 
litters of many domestic animals, and Hellin states that the ovaries of 
women who have had a number of multiple pregnancies contain an 
excessive quantity of ova. According to this view, which can apply 
only to double ovum twins, we have to deal with the maturation and 
fertilization of several ova at a single ovulation period. If heredity 
is concerned in such cases it can be manifested only by the transmission 
of abnormally actively functioning ovaries. 

Biologically, double ovum twins are not twins at all, but are simply 
due to the maturation and fertilization of two ova at a single ovulation 



b.L £a r 

Fig. 332. —Ovum with Dou¬ 
ble Germinal Vesicle. 








404 


MULTIPLE PREGNANCY 


period. Single ovum twins, on the contrary represent twins par ex¬ 
cellence, as is well expressed in Newman’s definition—“Strictly speak¬ 
ing, twinning is twaining or two-ing—the division of an individual into 
two equivalent and more or less completely separate individuals. 

Their mode of production has given rise to a considerable literature, 
to which American investigators have made important contributions. 
Formerly, it was believed that single ovum twins were derived from the 
fertilization of an ovum which presented two germinal vesicles. The 
existence of such ova is indisputable. Franque, Klein, and others ha\ing 
reported undoubted examples of such a condition; while Fig. 332 rep¬ 
resents an ovum of this character found in one of my specimens. When, 
however, one considers that in order for such an ovum to develop into 
single ovum twins each of its nuclei must undergo typical maturation 



Fig. 333. —Placenta, Double-ovum Twins, Velamentous Insertion of Cord. 


and cast off polar bodies, and moreover each of the female pronuclei 
so resulting must be fertilized by a separate spermatozoon, it is apparent 
that the process is not so simple, as might appear at first sight. Further¬ 
more, the problem is not simplified by accepting the hypothesis of 
Bromann, and Delucca and Widakowich, that fertilization may be effected 
by the two heads of a double-headed spermatozoon, whose occurrence 
they suppose is not infrequent. 

For a time Bonnet’s theory, that one of the two single ovum twins 
might originate from the fertilization of the second polar body before 
it had escaped from the ovum, enjoyed a considerable vogue, but now 
it finds few supporters. Recent biological investigations have shown 
that single ovum twinning occurs frequently in many species of animals, 
and can be produced experimentally and at will in several varieties of 



ETIOLOGY 


405 


fish, and also that it is fundamentally associated with the production 
of monstrosities—the normal twins representing the complete and the 
monstrosities an imperfect form of the same process. 

Stockard has shown that retardation in the growth of the egg, at 
m hat he calls critical periods of development; is the essential factor 
concerned; and has demonstrated that it may be brought about either 
by exposing the egg to cold or by diminishing its supply of oxygen. 
When exposed to such retarding influences; just as it is about to undergo 
gastrulation, the egg may die; or its developmental rate may be arrested 
01 slow ed down for a time, with the result that when growth is resumed 
two gastrulae or two embryonic areas will develop instead of one. If 
these are far apart two separate individuals will be formed, whereas if 
the .two areas are partially in contact double monsters presenting vary¬ 
ing degrees of fusion will result. 

Furthermore, Stockard has shown that he can alter at will the degree 
of duplicity by changing the time at which the retarding influences are 
brought into play. In other w r ords, he has adduced experimental proof 
of the closest relationship between single ovum tv-ins and double 
monsters, and in human beings one can readily follow all gradations 
between typical identical twins and the well-known Siamese twins on 
the one hand, and the double-bodied, double-headed or double-legged 
monsters downward to the monsters by inclusion, and finally to the 
teratomata, on the other. 

The most striking example of the development of multiple pregnancy 
from a single egg is afforded by the nine-banded armadillo. As is w^ell 
knowm, this animal gives birth to four young at a time, which are al¬ 
ways of the same sex and all of which are inclosed within a common 
chorion. All details of the process have been exhaustively worked out 
by New-man and Patterson, and it would appear that the key to the 
process lies in the fact that the fertilized ovum lies quiescent in the 
uterine cavity for three weeks before placental attachments are formed, 
and the resulting retardation in.growth during this period of quiescence 
causes a partial loss of polarity, so that when growth is resumed four 
embryonic areas result instead of one. 

That something of the same kind applies in human beings is indicated 
by the fact that Arey has demonstrated that twins occur many times 
more frequently in tubal than in uterine pregnancy, and he is inclined 
to attribute the difference to the difficulty attending the implantation 
of the ovum in the abnormal location, with consequent retardation of 
growth. 

Newman in his two monographs—The "Biology of Twins, and the 
Physiology of Twinning—has considered in detail the problems con¬ 
cerned in human beings. lie states that single ovum twins may be 
due to (i)« ssion of the blastoderm, (2) double gastrulation, or (3) 
fission of the bilateral halves of a single embryonic axis. In each in¬ 
stance some retarding factor must come into play, and he considers 
that any one of the following three possibilities may be concerned: 

(a) Understimulation of the egg due to some defect in the develop¬ 
ment-stimulating mechanism of the sperm. 


40G 


MULTIPLE PREGNANCY 


(&) Belated placentation due to a failure of the corpus luteum to 
stimulate the uterine mucosa, and 

(c) That twinning is an hereditary character dependent upon a 
recessive gene. 

While such explanations may not be entirely satisfactory, enough 
has been said to indicate that single ovum twinning is a well recognized 
biological phenomenon; does not represent an inherent attribute of the 
ovum, and is attributable to conditions which effect its rate of growth 
after fertilization. Accordingly, in human beings at least, its cause may 
sometimes be sought in environmental conditions with which we are as 
yet unacquainted. 

In Fig. 127 (page 124) is shown one of the earliest examples of 
human single ovum twinning. In this specimen, which was described 
by Streeter, the main embryo was a relatively large structure, while the 
twin was represented by a small amniotic vesicle and yolk sac imbedded 
in the connective tissue of the chorionic membrane, just adjoining the 
body stalk of the larger twin. 

Saniter states that in triplet pregnancy the children are usually 
derived from two ova—one from one, and two from the other—while 
in rare cases, one of which he has studied personally, all three children 
were derived from a single ovum. In the quintuplet pregnancy de¬ 
scribed by De Blecourt and Nijhoff, three of the children were con¬ 
nected with a single placenta, while each of the other two had separate 
placentae; thus indicating that only three ova had been fertilized, one 
giving rise to triplets, and the other two to single children. 

Relation of the Placentae and Membranes. —The development of one 
child in either horn of a bicornuate uterus, or of one twin in the uterus 
and the other in a fallopian tube, affords indubitable evidence of their 
origin from two ova; while in uterine twin pregnancy, the examination 
of the placenta and foetal membranes after labor usually enables one 
to determine the mode of origin of the twins. When they are derived 
from a single ovum, there is a single large placenta from which the 
two umbilical cords come off; but, when they are developed from two 
ova, there are usually two separate placentae, although, when these 
were originally inserted near one another, their contiguous margins 
may fuse together, thus giving rise to an apparently single large placenta, 
in which, however, there is no connection between the circulation of the 
two twins. 

In double-ovum twins, no matter whether the placentae are sep¬ 
arate or fused together, there are always two chorions and two amnions, 
each child being enveloped in its own membranes. Single-ovum twins, 
on the other hand, possess only a single chorion, but, as a rule, two 
amnions, for the reason that the former represents the wall of the 
original blastodermic vesicle, while the amnion is more directly con¬ 
nected with the embryo itself. In rare instances a single amnion is 
found. This condition, which was noted in 44 cases collected from 
the literature by Holzapfel, is not primary, but results from perforation 
of the partition wall between the two original amniotic cavities. 

This arrangement of the membranes was known to Viardel in the 


RELATION OF THE PLACENTAE AND MEMBRANE 


407 



a. 


seventeenth century, who stated that when the children were of the 
same sex they were usually inclosed in a single amnion; whereas 
twins of different sexes were separated by a partition wall. He ex¬ 
pressed the belief that Providence took this means of guarding their 
morals in utero. Saniter has care¬ 
fully studied the relation of the foetal 
membranes in triplet pregnancy. 

In single-ovum twins there is al¬ 
ways a certain area of the placenta 
in which there is anastomosis be¬ 
tween the two vascular systems, which 
is never present in the fused placenta 
of double-ovum twins. This condi¬ 
tion, which has been exhaustively 
studied by Schatz, and well reviewed 
by Newman, occasionally leads to seri¬ 
ous consequences. Thus, if at an 
early period the heart of one embryo 
is considerably stronger than that of 
the other, a gradually increasing 
area of the communicating portion of 
the placenta is monopolized by the 
former, so that its heart increases 
rapidly in size, while that of the lat¬ 
ter receives less and less blood and 
eventually atrophies. Herein is to be 
found the explanation of the de¬ 
formity known as acardia. In such 
cases almost the entire placental cir¬ 
culation is utilized by the normal em¬ 
bryo, while the deformed twin re¬ 
ceives only enough blood to nourish its 
lower extremities; while occasionally 
it is represented only by a shapeless 
mass of tissue—acardius amorphus. 

In other instances a difference in 
the strength of the two hearts leads 
to the production of hydramnios in 
the larger ovum. In such cases it is 
believed that the stronger heart ap¬ 
propriates an ever-increasing share of 
the blood from the placenta and 
undergoes hypertrophy, which in turn 
is followed by a marked hypertrophy 
of the kidneys, which leads to in¬ 
creased urinary secretion and a consequent excess in the quantity of 
amniotic fluid. 

In the rare instances in which single-ovum twins are inclosed in a 
common amnion, their umbilical cords mav become so twisted about 

( 




Fig. 334.—Diagram Showing Rela¬ 
tion of Placenta and Mem¬ 
branes in Double- and Single¬ 
ovum Twin Pregnancy. 

a, double-ovum twins; b, double-ovum 
twins, double membranes, single pla¬ 
centa; c, single-ovum twins, one cho¬ 
rion, two amnions, and one placenta. 














408 


MULTIPLE PREGNANCY 


one another as to interfere with the circulation through them, and thus 
lead to death and an early termination of pregnancy. Sonntag, in 1905, 

collected 23 such cases from the litera- 



Fig. 335. 




Fig. 337. 


tu re. 

Ordinarily in twin pregnancies, 
whether derived from one or two ova, 
each ovum occupies, roughly speaking, 
one-half of the uterus, the long axis 
being directed vertically. Occasionally, 
however, they run transversely, so that 
one foetal sac comes to lie above the 
other. In such circumstances, the pla¬ 
centa and membranes of the first child 
must be expelled from the uterus be¬ 
fore the second child can he born, un¬ 
less the latter can make its way past 
them. 

LTnless the uterus is distended by 
an excessive amount of amniotic fluid, 
its is evident that its more voluminous 
contents must be subjected to greater 
pressure than in the case of single 
pregnancies. In this event the twins 
are brought into the closest contact and 
may he markedly molded. Figs. 338 
-—a and from Filth's frozen section 
through the body of a primipara dying 
undelivered from eclampsia, give an 
excellent idea of what may happen, al¬ 
though it should be remembered that 
the conditions are probably exaggerated 
as the result of postmortem changes. 

Generally speaking, twins are 
smaller and weigh less than children 
resulting from single pregnancies, al¬ 
though their combined weight is 
usually greater than that of a single 
child. The smaller size may be con¬ 
sidered normal, but in some instances 
is partially to be explained by the fact 
that the excessive distention of the 
uterus tends to premature labor, so that 
the twins are often born several weeks 
before maturity. According to Ribe- 


Figs. 335-337. —Diagrams Showing 
Position of Twins in Utero. 


mont-Dessaignes, this occurs in 83 per 
cent, of primiparae, and in 75 per cent, 
of multiparae. 

It is not unusual for twins to differ considerably in size and weight, 
especially when derived from a single ovum. Ahlfeld has reported three 








SUPERFECUNDATION AND SUPERFETATION 


409 


cases in which the twins weighed, respectively, 2,320 and 1,120, 2,700 
and 1,650, and 1,920 and 790 grams. 

In double-ovum twin pregnancy one child may die at an early period 
and be expelled from the uterus soon afterward, while the other may 
go on to full development. More frequently, however, the dead foetus is 
retained until the end of pregnancy, and, being compressed between the 
uterine wall and the membranes of the living child, becomes flattened 
out and partially mummified —foetus papyraceus or compressus (Fig. 
339). 

Superfecundation and Superfetation.—The consideration of the dif¬ 
ference in the weight of twins, and the possibility of one being aborted 



Fig. 338A. —Showing Moulding of Fig. 338B. —Showing Moulding of 
Twins (Futh). Twins (Fiith). 


while the other develops until full term, leads up to the question of 
superfecundation and superfetation. By the former, we understand the 
fertilization of two ova within a short period of one another, but not 
at the same coitus; whereas in the latter several months may intervene. 

Superfecundation is a well-recognized occurrence in the lower 
animals, and undoubtedly occurs in human beings, although it is im¬ 
possible to determine its frequency. It is probable that in many cases 
the two ova are not fertilized at the same coitus, but this can be demon¬ 
strated only under exceptional circumstances. It is interesting to note 
that Dr. John Archer, who was the first physican to receive a medical 
degree in America, related in 1810 that he had observed a white woman, 
who had had connection with a white and a colored man respectively 
within a short period, and was delivered of twins, one of which was 



410 


MULTIPLE PREGNANCY 



white and the other a mulatto. Some years ago in my clinic, the sixth 
pregnancy of a colored woman terminated in the birth of twins, one 
being macerated and the other perfectly healthy. Autopsy and the 
microscopic examination of the placenta of the first child gave indubitable 
evidence of syphilis, while the second child showed no signs of the 
disease. On questioning the patient, who presented no manifestations 
of syphilis, it was ascertained that she had had connection with her 
husband and with another man within a period of a few daws, and 
that the latter was under treatment for syphilis at the time. From 

this it might be inferred that the normal child was engendered by the 

husband, and the 
syphilitic one by the 
lover, and the infer¬ 
ence is rendered more 
probable by the fact 
that the patient was 
delivered in the ser¬ 
vice twice before and 
thirteen times after 
this event, and none 
of the other children 
or placentae showed 
any sign of syphilis. 

• The occurrence 

v . s of superfetation has 

never yet been 
clearly demonstrated, 
_ though its theoretical 

Fig. 339.— Foetus Papyracues (Ribemont-Dessaignes) . possibility must be 

admitted,, as long as 

the uterine cavity has not become obliterated by the fusion of the 
decidua vera and reflexa. As this occurs at the end of the third month 
of pregnancy, superfetation is out of the question after that time; but 
prior to that there is no theoretical objection to supposing that, if 
ovulation should occur, a second ovum might find its way into the 
uterine cavity and there be fertilized. Still more favorable conditions 
would be afforded by a uterus duplex. 

Many French authorities consider that such an event has been 
conclusively demonstrated, and many of the arguments which have 
been advanced in its favor are given by Tarnier. On the other hand, 
most English and German authors are skeptical, and, while admitting 
its theoretical possibility, believe that the majority of instances put 
under this category have been due either to the abortion of one twin 
or to marked inequality of development. Moreover, the fact that ovula¬ 
tion is usually in abeyance during pregnancy still further diminishes the 
probability of such an occurrence. The arguments against .the occurrence 
of superfecundation were well reviewed by A. W. Meyer, in 1919. 

Cases occasionally occur which at first glance appear to bear out the 
possibility of superfetation, but, upon closer study, fail to do so. Thus, 




DIAGNOSIS 


411 


a physician sent me a specimen which he thought afforded conclusive 
evidence in favor of such an occurrence. It consisted of two foetuses, 
which had been expelled spontaneously by a healthy multiparous woman, 
who thought herself four and one-half months pregnant. One foetus 
measured 18, and the other 4 centimeters in length. The former was 
perfectly fresh, while the latter showed signs of atrophy and had evi¬ 
dently been dead for some time, so that there was but little doubt that 
each had begun development at about the same period. Even had both 
foetuses been alive, the evidence would not have been unassailable, unless 
both placentae presented identical conditions upon examination; as it is 
conceivable that some lesion might have been present in the placenta 
corresponding to the smaller child, which would seriously interfere with 
its growth, without, however, causing its death. 

Diagnosis.—It sometimes happens that the first intimation which 
the physician has of the presence of twins is afforded by the unusually 
large size of the uterus after the expulsion of the first child. Despite 
this fact, however, it may be said that such surprises will rarely occur 
in the practice of those who take the trouble to make a thorough pre¬ 
liminary examination. 

Excessive size of the abdomen during pregnancy frequently causes 
one to suspect the presence of twins, though usually it will be found 
to be due to some other condition. Thus, owing to the relaxation of 
the abdominal walls following the birth of the first child, women preg¬ 
nant for a second time often think that they will give birth to twins, 
although, as a matter of fact, their fears are generally without 
foundation. 

The diagnostic means at our disposal are palpation, auscultation, 
touch, and the N-ray. If a multiplicity of small parts is encountered on 
palpation, the possibility of a twin pregnancy should always be suspected. 
Positive evidence is afforded by the palpation of two heads, two breeches, 
and two backs; or at least of one back and four foetal poles. The 
detection of three foetal poles is not conclusive, for the reason that 
in rare instances a subperitoneal or intramural myoma may simulate 
the head of a child. 

Auscultation frequently gives most valuable information, and if 
one can distinguish two areas, considerably removed from one another, 
in which a foetal heart can be heard, twins should be suspected; but a 
positive diagnosis should not be made unless there is a difference of 
at least 10 beats per minute in the rate of the two hearts, the sounds 
being counted for at least a minute in each location. 

In rare instances vaginal touch may reveal important findings, as 
it is sometimes possible to distinguish a macerated head through the 
intact membranes, or a prolapsed and pulseless coid maj be felt through 
the cervix, while auscultation gives positive evidence of the presence of 

a living child. 

Gauss, in 1910, pointed out that the presence of a second chdd m 
utero may materially alter the manner of descent of the fiist through 
the pelvis. Accordingly, he considers that the existence of a twin preg- 







412 


MULTIPLE PREGNANCY 



nancy is indicated whenever vaginal examination shows a head deep in 
the pelvis in an anterior parietal presentation—that is, with the sagittal 
suture lying transversely and well posterior to the midline. 

In doubtful cases, the use of the Roentgen ray sometimes enables 
one to make a positive diagnosis by detecting the skeletons of tw r o chil¬ 
dren in the plate. On the other hand, a negative finding does not 
preclude the possibility of twins, as, owing to the unfavorable conditions 

under which the pic¬ 
ture must be taken, 
the presence of the 
second child may not 
be recognized. 

The presence of 
more than two chil¬ 
dren can be predicted 
with certainty only 
under very exceptional 
and favorable cir¬ 
cumstances, although 
Ribemont - Dessaignes 
reports the diagnosis of 
triplets during preg¬ 
nancy, and its confir¬ 
mation at the time of 
labor. 

Course of Labor.— 

We have already re¬ 
ferred to the enormous 
size of the uterus re¬ 
sulting from the pres¬ 
ence of twins, which 
may be still further in¬ 
creased by hydramnios 
of one ovum. This 
may give rise to con¬ 
siderable discomfort, 
the patient suffering 

Fig. 340. —Diagram showing Collision between maikedly from dysp- 

Heads of Twins. nea, pressure symp¬ 

toms, and edema. 

Occasionally the extreme stretching of the uterus may lead to an 
early dilatation of the cervix. Thus, in one instance, I found the 
cervical canal completely obliterated and the os externum dilated to 5 
centimeters three weeks before the onset of labor. Reference has 
all cad} been made to the frequency of premature expulsion in these 
cases; and when labor sets in, owing to the overdistention of the uterus, 
the pains usually occur at long intervals and are lacking in intensity! 
so that the birth of the first child is often prolonged. The cord of this 
child should be cut between double ligatures, as failure to ligate its ma- 









COURSE OF LABOR 


413 




ternal end may lead to the death of the second child from hemorrhage, if 
the twins are derived from a single ovum. 

Generally speaking, the membranes of the second child appear at the 
cervix immediately after the first is born and soon rupture. Its ex¬ 
pulsion usually follows the first within half an hour, 75 per cent, of 
the cases collected by Kleinwachtei” occurring within this period; 
while in the remainder a longer time elapsed—as much as twelve hours 
in 7 of his cases. If spontaneous delivery of the second child does 
not occur within a reasonable time, interference is indicated, and the 
practice formerly in vogue of waiting hours for its spontaneous expulsion 
cannot be reprehended too strongly. 

Changes in position of the second child frequently occur during 
and just after the birth of the first, so that at this time a renewed 
examination is necessary in order that any abnormality may be de¬ 
tected and the proper measures taken. The condition of the foetal heart 
should also be carefully watched, and delivery immediately effected 
if it becomes abnormal. 

As a rule the placenta of the first child remains in situ until the 
completion of labor, but in rare instances it may become partly or 
completely separated and give rise to hemorrhage. Under these cir¬ 
cumstances the second child should be delivered at once. 

In most cases both twins present by the vertex, though not very 
rarely one descends by the breech. In 1,849 cases analyzed by Leon- 
hardt, the following conditions were noted: 


First twin. 
Vertex, 
Vertex, 
Breech, 
Breech, 
Vertex, 
Breech, 
Transverse, 
Transverse, 
Transverse, 


Second twin. 
Vertex, 
Breech, 
Vertex, 
Breech, 
Transverse, 
Transverse, 
Vertex, 
Breech, 
Transverse, 


Per cent. 
38.53 
21.19 
14.35 
10.76 
8.32 
4.29 
0.87 
0.77 
0.92 

Total .100.00 


Except for the delay incident to uterine inertia, delivery in twin 
pregnancy usually causes but little difficulty, provided an accurate 
diagnosis of the presentation of the children has been made. Con¬ 
sequently, it is difficult to understand why many physicians approach 
the matter with grave forebodings, and fear that they may have to 
deal with one of the complications, which are about to be mentioned, 
but which occur so rarely that they may not be encountered by ob¬ 
stetricians of large experience. Occasionally, when the children are 
small in size, their presenting parts may both attempt to enter the 
superior strait at the same time, and thus mutually interfere with one 
another. This complication is known as collision, and may occur when 
both children present by the vertex, or when one presents by the head 
and the other by the breech. In the first case, an attempt should be 









414 


MULTIPLE PREGNANCY 


made to push up the presenting • part which is less distinctly engaged, 
and then to deliver the other child rapidly. If this is not possible, the 
whole hand should be intro due: i into the uterus and the condition of 
affairs carefully studied. Occasionally it will be found advisable to 
apply forceps to the uppermost child and attempt to drag it past the 
other. In rare instances craniotomy upon one child may be indicated. 

Now and again during extraction, when the first child presents by 
the breech and the second by the vertex, the two heads may become 
locked just above the superior strait, that of the second fitting into the 
neck of the first child and making its delivery impossible. Under such 
circumstances, if the head of the second child cannot be displaced, 
the first child should be decapitated, as it must inevitably perish during 
any attempt at extraction; after this 
the body should be brought away 
and the second child then delivered 
by forceps. 

In rare instances, the first child 
may present transversely and be 
straddled by the second in such a 
manner that the legs of the latter 
protrude from the cervix. Traction 
upon them will serve only to wedge 
the shoulder of the other child more 
firmly into the pelvis and give rise 
to insuperable difficulties. The 
proper treatment can only be deter¬ 
mined after careful examination un¬ 
der anesthesia, with the entire hand 
in the uterus, but when the condi¬ 
tion of affairs has been clearly visual¬ 
ized, a little mechanical ingenuity 

will readilv enable one to determine 
*/ 

whether version or decapitation is 
the operation of choice. 

Owing to previous overdisten¬ 
tion, the uterus sometimes fails to contract and retract satisfactorily 
during the third stage of labor, so that abnormalities in the placental 
perior are not infrequent. If there is any tendency toward an excessive 
loss of blood, the obstetrician should immediately express the placenta 
by Crede’s method, instead of waiting for the fundus to rise up. Occa¬ 
sionally the area of placental attachment may be so large that ab¬ 
normalities in its detachment may render necessary its manual removal. 
This operation, however, should not be resorted to unless urgently in¬ 
dicated. 

The danger of hemorrhage does not end with the expulsion of the 
placenta, as the uterus sometimes relaxes during the hour immediately 
following. Accordingly, the physician should remain with the patient 
for some time after the completion of labor and give his personal super¬ 
vision to the condition of the uterus, kneading it upon the first indi- 











LITERATURE 


415 


cation of relaxation, and reenforcing it by the hypodermic adminis¬ 
tration of ergot. Neglect in this direction has sometimes led to the 
death of the patient from postpartum hemorrhage. 


LITERATURE 

Ahlfeld. Die Entstehung der Doppelibildmigen end der homologen Zwillinge. 
Archiv f. Gyn., 1876, ix, 196-251. 

Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 356-362. 

Archer. Observations Showing That a White Woman, by Intercourse with a 
White Man and a Negro, May Conceive Twins, One of Which Shall Be White 
and the Other a Mulatto. Medical Repository, 1810, 3d Hexade, I, 319-323. 
Arey. The Cause of Tubal Pregnancy and Tubal Twinning. Am. J. Obst. & 
Gyn., 1923, v, 163-167. 

Badouin. La grossesse sextuple. Gazette med. de Paris, 1909, 157-159 and 
205-207. 

Bertillon. Bulletin de la soc. d ’anthropologie de Paris, 1874, ix, 267-290. 
Davenport. Influence of the Male in the Production of Human Twins. Am. 
Naturalist, 1920, liv, 122-128. 

De Blecourt u. Nijhoff. Fiinflingsgeburten. Groningen, 1904. 

Delucca and Widakowich. Recherches sur l’origine des gestations gemellaires 
uni-ovularies. Annales de Gyn. et d’Obst., 1919, xiii, 722-732. 

Duncan. On Some Laws of the Production of Twins. Edinburgh Med. Jour., 
March, 1865. 

von Franque. Besclireibung einiger seltener Eierstockspraparate. Zeitschr. f. 
Geb. u. Gyn., 1898, xxxix, 326-346. 

Futh. Medianer Gefrierschnitt durch den Rumph einer an Eklampsie gestorbenen 
Erstgebarenden mit Zwillingen. Wiesbaden, 1918. 

Gache. La fecondite de la femme dans 66 pays. Buenos Aires, 1904. 

Gauss. Ein neues Zeichen fiir die Diagnose der Zwillingsschwangerschaft. Zen- 
tralbl. f. Gyn., 1910, 1281-1296. 

Hellin. Die Ursache der Multiparitat der uniparen Tiere, etc. Miinchen, 1895. 
Holzapfel. Zur Pathologie der Eihiiute., Beitrage z. Geb. u. Gyn., 1903, viii, 
1-32. 

Klien. Ueber mehreiige Graaf’sche Follikel beim Menschen. Miinchener med. 

Abhandlungen, 1898, IV. Reihe, Heft 4. 

Kleinwachter. Die Lehre von den Zwillingen. Prag, 1871. 

Larger. Les stimates obstetricaux de la degenerescence. These de Paris, 1901. 
Leonhardt. Ueber die Kindeslagen bei Zwillingsgeburten. D. I., Berlin, 1897. 
Meyer. The Occurrence of Superfetation. Jour. Am. Med. Assoc., 1919, lxxii, 
767-774. 

Mirabeau. Ueber Drillingsgeburten. Miinchener med. Abhandlungen, 1894, IV. 
Reihe, Heft 5. 

Newman. The Biology of Twins. Chicago, 1917. 

The Physiology of Twinning. Chicago, 1922. 

Nichols. Sex Ratio of Twins. Memoirs Am. Anthropological Ass., 1907, I. 
Patellani. Die mehrfachen Schwangerschaften, etc. Zeitschr. f. Geb. u. Gyn., 
1896, xxxv, 373-413. 

Paterson and Newman. The Development of the Nine-banded Armadillo, etc., 
Jour. Morphol., 1910, xxi. 

Prinzing. Die Haufigkeit der eineiigen Zwillinge. Zeitschr. f. Geb. u. Gyn., 
1908, Ixi, 296-308. 


416 


MULTIPLE PREGNANCY 


Puech. Des grossesses multiples, etc. Paris, 1873. 

Ribemont-Dessaignes et Lepage. Precis d ’Obstetrique, 1894, 864-897. (Gros- 
sesse gemellaire.) 

Saniter. Drillingsgeburten. Eineiige Drillinge. Zeitschr. f. Geb. u. Gyn., 1901, 
xlvi, 347-385. 

Schatz. Die Gefassverbindungen der Placentakreislaufe eineiiger Zwillinge, ihre 
Entwickelung und ilire Folgeu. Archiv f. Gyn., 1882-1900, Bde. xix, xxiv, 
xxvii, xxix, xxx liii, lv, lviii und lx. 

Sobotta. Eineiige Zwillinge und Doppelmissbildungen. Meyer u. Schwalbe, 

Studien der Pathologie der Entwickelung. 1914, I, H. 3, 394-427. 

Sonntag. Verschlingung u. Knotenbildung der Nabelscliniire. D. I., Leipzig, 
1905. 

Stockard. An Experimental Study of Twins, Double Monsters and Single De¬ 
formities. Am. Jour. Anat., 1921, xxviii, 115-266. 

Streeter. Formation of Single Ovum Twins. Bull. Johns Hopkins Hosp., 1919, 
xxx, 235-238. 

Tarnier et Chantreuil. Des grossesses multiples. Traite de l’art des accouche- 
ments, Paris, 1888, t. i. 543-563. 

Veit, G. Beitrage zur geburtshiiltliehen Statistik. Monatsschr. f. Geburtsk., 
1855, vi, 126-132. 

Viardel. Anmerkungen von der weiblichen Geburt. Frankfurt, 1676, 21. 

Wappaeus. Allg. Bevolkerungsstatistik. Leipzig, 1859. 




INDUCTION OF ABORTION 


419 


subjected to repeated examinations or attempts at delivery, a vaginal 
douche of a 1 to 5,000 bichlorid solution may be given, although I do 
not employ it. 

Before the sterile dressings are put in place, the bladder should 
be emptied by means of a sterile rubber catheter. In the early months of 
pregnancy, a distended bladder interferes with bimanual manipula¬ 
tions, at labor it may affect the engagement of the presenting part, and 
after the birth of the child it may interfere with the proper conduct 
of the third stage of labor. 

Obstetrical operations, with the exception of podalic version, cesarean 
section and other laparotomies, are usually undertaken with the patient 
in the lithotomy position. In hospitals, a suitable operating table is 
always available; while in private practice, as the low beds now in use 
are very inconvenient, it is advisable to place the patient upon a narrow 
table: one that will answer the purpose quite satisfactorily is usually to 
be found in every kitchen, but, if a suitable table is not available, a 
satisfactory makeshift may be improvised by unscrewing the mirror 
from a bedroom bureau. Anesthesia is indispensable for all but the 
simplest procedures, and if it is to be prolonged, ether is safer than 
chloroform, on account of the late poisoning which sometimes follows 
the use of the latter drug. As soon as the patient is fully under its 
influence, her buttocks should be brought to the edge of the table, and 
her legs held in place by a leg-holder. The nightgown should be rolled 
up above the hips to avoid soiling, and, as soon as the external genitalia 
have been prepared, the legs should be encased in sterile leggings, and 
the abdomen and buttocks covered with sterile towels in such a manner 
as to leave only the genitalia exposed. To avoid the possibility of con¬ 
tamination from the rectum, it is advisable to cover the anus with a 
folded sterilized towel, which can be held in place by a strip of ad¬ 
hesive plaster passed over the buttocks, or better still by small clip 
forceps which attach it directly to the skin. Finally, a specially prepared 
sterile sheet should cover everything except the immediate field of 
operation. 

Induction of Abortion.—By this term is understood the artificial 
termination of pregnancy before the foetus has attained viability * 
namely, prior to the twenty-eighth week. The operation dates from 
the most remote antiquity, and more or less accurate directions for 
its performance are to be found in the earliest writings upon medicine. 
It was so extensively practiced in Rome that we find it repeatedly le- 
ferred to by Plautus, Juvenal, and other secular writers as a matter 
of every-day occurrence. With the spread of Christianity, however, it 
came to be considered as criminal, except when undertaken as a last 
resort in order to save the life of the mother; and we now draw a sharp 
distinction between criminal and therapeutic abortion. For historical 
details the reader is referred to the works of Levin and Brenmng, 

Brouardel, and Kleinwachter. . 

Indications .—Three groups of conditions may offer an indication tor 
the operation. Thus we may think it our duty to induce a therapeutic 
abortion: (1) As a direct means of saving the life of the mother; 


420 INDUCTION OF ABORTION AND PREMATURE LABOR 






I 


(2) to do away with a condition which may threaten her life if gesta¬ 
tion continues; and (3) to avoid certain dangers which may supervene 
if pregnancy is allowed to progress to full term. 

Under no circumstances should an abortion be undertaken, unless a 
careful and thorough examination has demonstrated that the condition 
of the patient is really serious. Her statements are entitled to but 
little weight, and the decision to interfere should be based entirely upon 
objective symptoms and clinical findings. Moreover, it should never 
be done without consultation with a second physician, who assumes 
his share of the responsibility. This precaution, besides securing for 
the patient additional advice, will protect the physician from possible 
blackmailing on the part of unscrupulous persons. 

In the first group, the best-recognized indication for the operation 
is afforded by pernicious vomiting of 'pregnancy. In most instances 
this condition is neurotic in origin and can be cured by appropriate 
measures. More rarely, however, the vomiting is a manifestation of 
a profound toxemia, as will be described in the chapter on the toxemias 
of pregnancy. If the latter diagnosis be established, the prompt induc¬ 
tion of abortion is urgently demanded, as we know by experience that 
it offers the only hope of saving the life of the patient. 

Prior to the recognition of the varying nature of this condition, 
there was a natural hesitancy on the part of the physician to interfere 
owing to the fact that in many cases the vomiting ceased spontaneously, 
or was relieved by treatment. For that reason, the operation was fre¬ 
quently postponed until the condition of the patient had become so 
serious that death was the inevitable consequence, whether abortion 
was induced or not. Now that we know more about it, interference 
is rarely necessary in neurotic vomiting, but is imperative in the toxemic 
type. 

The induction of abortion is likewise urgently indicated when the 
uterine contents have become infected, a condition which frequently 
follows attempts at criminal abortion. Under such circumstances, if 
the foetus has not already succumbed it will almost certainly die, and 
the greatest chance of saving the woman’s life lies in promptly emptying 
the uterus and cleaning its cavity. 

Formerly it was believed that abortion should be induced for in¬ 
carceration of the retroflexed pregnant uterus , as well as in the rare 
cases of hernia of that organ, inasmuch as death may result if the 
patient be left to herself. At present, however, unless infection has 
supervened, better results are obtained in the former condition by per¬ 
forming laparotomy, freeing the uterus from adhesions and replacing 
it in a normal position, after which pregnancy may pursue an uninter¬ 
rupted course. 

In the second group, preeclamptic toxemia or pronounced renal insuf¬ 
ficiency may necessitate the operation. But inasmuch as such condi¬ 
tions usually develop later in pregnancy, they will be considered when 
we take up the induction of premature labor. With the extension of 
renal surgery, it is not uncommon for pregnancy to. supervene in women 
from whom one kidney has been removed. If the remaining organ is 














INDUCTION OF PREMATURE LABOR 


425 


The question as to the propriety of the operation has given rise to 
an extensive literature. At the International Medical Congress of 1890, 
it was one of the chief subjects under discussion, when Sanger was 
practically the only speaker who opposed its employment in moderate 
degrees of pelvic contraction. With increasing knowledge as to the 
course of labor in contracted pelves, together with the generally good 
results following classical cesarean section, and other radical obstetrical 
operations, a marked change in sentiment has occurred, and the induc¬ 
tion of labor has lost greatly in popularity. 

It is now generally recognized that from 70 to 80 per cent, of all 
labors complicated by contracted pelvis, including the cases of pro¬ 
nounced deformity which require radical interference, will end spon¬ 
taneously if treated expectantly. With this fact in mind, Pinard, Bar, 
Kronig, myself, and others hold that the induction of premature labor 
is no longer justified, and that in cases of moderate pelvic contraction 
equally good results for the mother, and far better results for the child, 
will be obtained by abstaining from the former operation, and sub¬ 
jecting to cesarean section at term all patients who present such dis¬ 
proportion between the size of the head and the pelvis as makes a 
spontaneous outcome unlikely. 

Following these principles, 829 patients presenting contracted pelvis 
of all grades were treated in my clinic up to July, 1910, and 74.76 
per cent, were delivered spontaneously; 90.3 per cent, of the children 
left the clinic in good condition, and upon deducting the cases in which 
the child was dead at the time of admission of the mother, or died 
from such extraneous causes as syphilis, bronchopneumonia, etc., the 
net foetal mortality due to the pelvic contraction was 4 per cent. 

The principal difficulty connected with the induction of labor is to 
recognize the cases which will require it, and to choose the correct time 
for its performance. Unfortunately, we are unable to determine accu¬ 
rately the size of the child’s head, and more particularly its degree of 
compressibility and ossification. The methods of Muller, Ahlfeld, and 
others, to which reference will be made in the chapter upon the treat¬ 
ment of contracted pelves, do not lead to very accurate results, so that 
the operation is frequently performed unnecessarily. 

The results obtained are satisfactory so far as the mother is con¬ 
cerned, the maternal mortality being only 1.03 per cent, in 391 opera¬ 
tions reported by Ahlfeld, Bar, Leopold, and Pinard. On the other 
hand, the foetal mortality is relatively high, varying from 12 to 45 per 
cent. Kleinwachter, after an exhaustive study-of the subject, concludes 
that 78.3 per cent, of the children are born alive, but that only 60.4 
per cent, leave the hospital in good condition, which means an immediate 
net mortality of 39.6 per cent. Furthermore, when we consider that 
careful nursing and appropriate feeding are afterward necessary, it is 
apparent that no inconsiderable portion of the children dismissed from 
the hospital in good condition must inevitably perish within the first 
year, and it is hardly an exaggeration to state that scarcely one half 
of those born alive survive that period. It would, therefore, appear 
that the ultimate results, so far as the children are concerned, are 







426 INDUCTION OF ABORTION AND PREMATURE LABOR 


so poor as not to commend the operation to favorable consideration, 
and that equally good results would be obtained by treating all cases 
expectantly, and performing craniotomy whenever operative delivery be¬ 
came necessary. As such a course would be a reductio ad absurdum, 
it follows that the operation should be abandoned. In my entire ex¬ 
perience, I have employed it in only one case of contracted pelvis, and 
have no cause to regret my action. It must, however, be admitted that 
all authors do not share this view, as Norris, Herlf, and others contend 
that their results are fairly satisfactory. 

The most usual indication for the operation, however, is afforded 
by diseases which threaten the life of the mother, while at the same 
time there exists a probability of cure after the termination of gesta¬ 
tion. This is particularly true in those cases of preeclamptic toxemia 
or chronic nephritis complicating pregnancy, which show' no tendency 
to subside in spite of appropriate treatment. Experience teaches that 
under such circumstances, even if pregnancy be allowed to continue, 
premature labor frequently occurs spontaneously, when a large propor¬ 
tion of the children are born dead, or, if born alive, they are very 
imperfectly developed. Accordingly, if threatening symptoms supervene, 
labor should be induced at any period of pregnancy without too con¬ 
servative a regard for the life of the child; as the ideal method of 
treating eclampsia is to prevent its occurrence. 

Cardiac lesions occasionally demand the induction of premature 
labor, but this should be resorted to only in cases of broken compen¬ 
sation, which do not yield to appropriate treatment. In many instances, 
more radical intervention by means of cesarean section followed by 
supravaginal hysterectomy is preferable. 

From the time of D’Outrepont (1828), it has been recommended 
that the operation be undertaken in the interests of the child in the 
rare cases of tuberculosis in which the condition of the mother is so 
serious as to make it probable that she will not live until term. 

Spontaneous interruption of pregnancy frequently occurs during the 
course of the acute infectious diseases—influenza, pneumonia, typhoid 
fever, etc.—but, inasmuch as experience has shown that it materially 
increases the risks to the mother, the induction of premature labor is 
contra-indicated. 

In rare instances a general peripheral neuritis may so endanger 
the life of the mother as to call for interference. Lepage and Sainton 
(1901) reported a case of alcholic origin in which the induction of 
labor was followed by most happy results. 

The milder forms of chorea complicating pregnancy are usually 
amenable to treatment, but when the disease assumes a grave type it 
is attended with great danger, the maternal mortality, according to 
Fehling, being 36 per cent. Therefore, if the patient appears to be 
in serious danger, premature delivery should be brought about, as 
experience has shown that the emptying of the uterus is sometimes 
followed by pronounced improvement. 

In patients suffering from true diabetes, gestation sometimes exerts 
a very deleterious influence upon the course of the disease. Usually, 




INDUCTION OF PREMATURE LABOR 


427 


however, the diabetic patient improves during the latter part of preg¬ 
nancy, supposedly as a result of the activity of the foetal pancreas. 
In several of our patients, who have been followed for a number of 
years, sugar free intervals while upon a normal diet were observed 
only during the last months of pregnancy and early in the lactation 
period. For these reasons, the induction of premature labor is rarely 
indicated, and, when carried out, rarely does good. Moreover, it should 
be remembered that in the majority of cases the so-called diabetes of 
pregnancy is merely a lactosuria which is not likely to be attended by 
serious symptoms. 

According to Graefe and Winter, the occurrence of pregnancy in 
patients suffering from pernicious anemia or leukemia adds markedly 
to the gravity of the condition, so that in occasional cases the induction 
of premature labor may be indicated. 

In patients suffering from pyelitis, the pregnant uterus may so 
compress the ureter as to cause a damming back of the purulent dis¬ 
charge, and thus give rise to a pyelonephrosis. In such circumstances 
! the induction of premature labor is indicated. Fortunately, however, 
such interference is rarely necessary, as with rest in bed and ap¬ 
propriate dietary and medicinal treatment the results are surprisingly 
good. 

Formerly the induction of premature labor was recommended when 
pregnancy is complicated by uterine or ovarian tumors , or by malig¬ 
nant disease of the uterus or rectum, which would offer an insuperable 
obstacle to the birth of a full-term child. At the present day, how- 
; ever, such indications are not tenable. What has already been said in 
connection with the induction of abortion under similar conditions also 
holds good here. 

In hydramnios, when the abdomen is so distended as seriously to 
threaten the life of the patient, pregnancy should be terminated with¬ 
out too much regard for preservation of the child, as in many such cases 
it is so poorly developed as to have but little chance of living, even 
if born at full term. 

Whenever placenta previa is positively diagnosed, the termination 
of pregnancy is urgently indicated, as it is impossible to predict at 
what moment uterine contractions may come on and give rise to profuse 
or even fatal hemorrhage. 

In rare cases of habitual death of the foetus in the later months of 
pregnancy, when not due to syphilis or renal disease, the induction of 
premature labor has been recommended at a time slightly anterior to 
. that at which foetal death has occurred in previous pregnancies, in the 
hope that a living child may be obtained. In such cases the operation 
may be undertaken if the parents are extremely anxious for a living 
j child, although in no instance should a positive assurance of success be 
held out to them. 

One of the most important and defensible indications for the in¬ 
duction of labor is afforded by the so-called postmature child. Whenever 
during the last weeks of pregnancy palpation shows that the child ex¬ 
ceeds °the usual limits of size, and particularly in multiparae who give 





42S INDUCTION OF ABORTION AND PREMATURE LABOR 


a history of dystocia resulting from excessive bulk of the child, labor 
should be induced, as it appears irrational to allow conditions predis¬ 
posing to dystocia to develop without interference. 

The same holds good in cases of prolonged pregnancy, and the 
physician should make it a rule to examine each week every patient 
whose history indicates that the calculated duration of gestation has 
been exceeded. Ordinarily, the child will be found normal in size, but 
when its development appears to be excessive or evident disproportion 
exists, labor should be induced immediately. 

As such indications are in great part dependent upon one’s personal 
judgment, the greatest care should be exercised in arriving at a de¬ 
cision, and interference practiced only when clearly demanded by the 
physical findings. The induction of labor at a fixed date merely to 
suit the convenience of the patient or obstetrician cannot be repre¬ 
hended too strongly, and should the outcome in such a case be un¬ 
favorable, nothing could be said in its defense. 

Prognosis .—As far as the mother is concerned, the prognosis of 
the induction of premature labor is excellent, provided a rigorous aseptic 
technic is observed and the physical condition is not critical at the 
time of the operation. 

The prognosis for the child depends, of course, upon the degree 
of its development, as well as upon the pathological condition for which 
the operation is undertaken. Generally speaking, in the case of children 
born before the thirty-second w r eek, the chances of surviving are very 
small, especially when nephritis or hydramnios affords the indication 
for interference. 

Methods of Inducing Premature Labor .—These may be medicinal 
or operative in character. The former are available only during the 
very last weeks of gestation, while the latter may be employed at any 
time after the child is viable. For this reason, the chief indications 
for attempting induction by medicinal means are afforded by the post- 
mature child or by prolongation of pregnancy, and in such circum¬ 
stances, it should always be employed before resorting to operative 
procedures. 

For years castor oil and quinine have been administered for this 
purpose, but the results have been so uncertain that when a positive 
outcome follows, one is usually in doubt whether to ascribe it to the 
treatment or to the coincident onset of spontaneous labor. Watson 
supplements the castor oil and quinine by the administration of pitu¬ 
itary extract, and has developed the following technic which he claims 
is very effective: 

6 p. m. castor oil 1 ounce, 

7 p. m. quine ten grains, 

8 p. m. large soap-suds enema, 

9 p. m. quinine ten grains, 

12 p. M. quinine ten grains. 

If pains have not supervened by nine o’clock the next morning, one- 
half cubic centimeter of pituitary extract is administered hypodermic- 





INDUCTION OF PREMATURE LABOR 


429 


ally, and repeated each half hour until labor sets in, or until six doses 
have been administered. 



In my hands, this technic has had the desired result in approxi¬ 
mately seven out of ten, instead of nine out of ten cases, as Watson 
claims. No untoward effects have been observed, and, as it is distinctly 
more efficient than the administration of castor oil and quinine alone, 
it should he employed in preference to operative means whenever haste 
is not essential. 

The simplest operative method of inducing labor 
is that of Scheele, which consists in perforating 
the membranes with a sharp instrument 
and allowing the amniotic fluid to drain 
off. The results, however, are uncertain, 
so that the procedure is applicable only 


Fig. 346a.—C hampetier de Ribes’ Bal¬ 
loon, DISTENDED. X 


in a very limited number of cases, 
more especially in hydramnios, and 


in marginal placenta previa. 

In the method most usually employed—that of Krause—a bougie is 
introduced between the membranes and the uterine wall. In carrying 
out this procedure the patient is placed in the dorsal or Sims’s position, 
and the external genitalia carefully disinfected. The cervix is then 
brought into view by means of a speculum, and one or more sterilized 
bougies are passed through it and gently carried high up into the 



uterine cavity, between the membranes and the uterine wall. I prefer 
the very thick-walled Wales’ bougies made by the Goodrich Company, 
which, while flexible, are* sufficiently stiff to be introduced without the 
aid of a stylet. 

The only objection to Krause’s method is its uncertainty. In many 
cases the introduction of the bougie is followed within a few hours 
by uterine contractions, which lead to the expulsion of the foetus after 
a' longer or shorter period. Occasionally, however, twenty-four hours 
may elapse without the appearance of pains. In the latter circumstances 















430 INDUCTION OF ABORTION AND PREMATURE LABOR 


the bougies should be removed, and the pregnancy terminated in some 
other manner. But in general, when haste is not essential, this is the 
safest and best method of procedure. 

More rapid results are obtained by the use of inflatable rubber 
balloons, but the greater manipulation incident to their introduction 
somewhat increases the possibility of infection. Those of Champetier 
de Ribes are conical rubber bags with reenforced walls, from whose 
small end extends a thick rubber tube provided with a stopcock. They 
are made in several sizes, the largest having a capacity of 500 cubic 
centimeters. If the cervical canal is 1.5 centimeters in diameter, the 
bag can be passed without difficulty, but if smaller, it should be dilated 
up to that size by means of a suitable dilator. The bag, which has 
been sterilized by boiling, is tightly rolled into cylindrical form, seized 
with an appropriately shaped forceps, thickly smeared with sterile vase¬ 
line, introduced into the lower uterine segment, and then pumped full 
of sterile salt solution. Within a few hours it usually so irritates the 
uterus as to induce contractions, which soon lead to dilatation of the 
cervix and the expulsion of the bag, after which the child can be 
extracted or labor allowed to end spontaneously, according to the ex¬ 
igencies of the case. Where greater haste is necessary, the dilatation 
may be accelerated by attaching a weight to the end of the tube and 
allowing it to hang over the foot of the bed. This method gives very 
satisfactory results, though it is evident that the introduction of the 
large bag into the lower uterine segment must displace the presenting 
part, and occasionally give rise to malpresentations. 

Tarnier’s excitateur uterin —a thin-walled rubber bag 3 or 4 centi¬ 
meters in diameter—and Barnes’s fiddle-bags are based upon the same 
principle, but their smaller size renders them much less efficient 
irritants. 

When the cervix is but slightly dilated, certain authorities recom¬ 
mend the use of a sterile tampon. In such cases the end of a sterilized 
4-inch roller gauze bandage is tightly packed into the cervical canal 
by means of a uterine dressing forceps, after which the vagina is firmly 
and tightly packed with the same material. The pack should be re¬ 
moved within twelve hours, and at the expiration of that period the 
cervix will often be found sufficiently dilated to permit of other maneu¬ 
vers. Generally speaking, I advise against its use, for, in addition to 
being uncertain in its action, even when introduced under the most 
rigid aseptic precautions, it is sometimes followed by infection. 

Numerous other methods for the induction of premature labor have 
been suggested from time to time, among which may be mentioned 
that of Cohen. This consists in the injection of 200 to 300 cubic centi¬ 
meters of aqua picis between the uterine wall and the membranes. Other 
writers have substituted various fluids. Thus, Pelzer suggested the use 
of 100 cubic centimeters of sterile glycerin, which promptly gives rise 
to uterine contractions. Its employment, however, is not to be recom¬ 
mended, as it is occasionally followed by serious symptoms of intoxi¬ 
cation, hemoglobinuria, albuminuria, elevation of temperature, cyanosis, 
and occasionally by death. Full details respecting the various other 


ACCOUCHEMENT FORCE 


431 


methods suggested for the induction of premature labor will be found 
in the monographs of Kleinwachter, Fieux, and Williamson. 

Accouchement Force. —By this term is understood the forcible dilata¬ 
tion, or clean cut incision, of the intact or partially dilated cervix, 
followed by the immediate delivery of the child. In pre-antiseptic times 
the operation was so universally followed by infection that it naturally 
fell into deserved disrepute; but it has since been rehabilitated, and 
when properly performed under suitable conditions has been the means 
of saving many lives. An excellent resume of the history of the opera¬ 
tion will be found in the dissertation of Ruhemann. Generally speaking, 
if the cervix be firm and hard and the canal not obliterated, forcible 
dilatation is apt to be very difficult and attended with considerable 
risk to the mother, so that its resistance had better be overcome by a 
cutting operation. On the other hand, when the cervical canal is prac¬ 
tically obliterated and resistance is offered only by the partially dilated 
external os, rapid dilatation is readily performed, and is followed by 
very satisfactory results. As a general rule, it is more difficult in 
primiparous than in multiparous women. 

Indications .—In this country the most usual indication for ac¬ 
couchement force is threatened or actual eclampsia. Occasionally it 
becomes necessary in concealed or accidental hemorrhage, or in other 
conditions which threaten the life of the mother or child, such as acute 
edema of the lungs, broken cardiac compensation, or in exceptional cases 
of prolonged labor in which the life of the child is endangered. It 
should, however, not be employed in placenta previa. 

Manual Dilatation .—If labor has already begun, the cervical canal 
is obliterated, and the resistance is offered only by the external os, 
which is five or more centimeters in diameter, excellent results are 
obtained by the method of manual dilatation suggested by Philander 
A. Harris. But if labor has not set in, and the cervix is intact and 
hard and rigid, the operation is both difficult and dangerous; and if 
the attempt at dilatation be forcibly persisted in, it gives rise to deep 
tears through the cervix, and occasionally through the lower uterine 
segment as well, which may lead to the death of the patient from 
hemorrhage or infection. Generally speaking, if rapid delivery is 
urgently demanded under such conditions, it should be effected by 
vaginal hysterotomy, or by caesarean section. 

At the time of operation the patient should be profoundly anes¬ 
thetized and the most rigorous aseptic technic applied. After ironing 
out the vaginal opening and the pelvic floor by the thoroughly lubricated 
hand, the index finger is carried up the cervical canal and through 
the internal os, and followed as soon as possible by the second finger. 
When this has been accomplished, completion of the dilatation is usually 
comparatively easy. The dilating force is exerted by the back of the 
thumb, which is pushed past the index finger with much the same 
motion 'as is employed in snapping one's fingers; then, as dilatation 
progresses, past two, three, and finally all four fingers. These maneu¬ 
vers are clearly shown in Fig. 347. 

When the internal os is already obliterated, complete dilatation of 


432 INDUCTION OF ABORTION AND PREMATURE LABOR 


the cervix can be readily effected by Harris’s method within half an 
hour. I employed this method 83 times in the first 5,000 cases de¬ 
livered in the Johns Hopkins Hospital, and found it very effective, and 
am able to confirm all that Harris has claimed for it. It should, 
however, be remembered that it is not devoid of danger, for if em¬ 
ployed before the external os has dilated to a diameter of five centi¬ 
meters, it is always associated with laceration, whose extent cannot 
be controlled. Its use ^s especially contra-indicated in placenta previa 
on account of the increased liability to deep cervical tears, and even 
to rupture of the uterus. 

Furthermore, the operator should bear in mind that the liability to 
laceration is greater the more rapidly dilatation is effected, and he 
should therefore be careful to avoid undue haste. This caution is the 
more necessary, as there seems to be an irresistible tendency to over¬ 
estimate the time consumed in the process, and from my own experi- 



Fig. 347. —Diagrams Illustrating Manual Dilatation of Cervix (Harris). 


ence I know that what may seem to be a long time to the operator is 
often in reality only a few minutes. For this reason, it is always well 
to control the rapidity of dilatation by watching the clock, as in such 
circumstances one should judge of the excellence of an obstetrician by 
the deliberation, rather than by the rapidity, with which he operates. 

Edgar and Bonnaire have described bimanual methods of dilatation, 
which they claim give most satisfactory results. I have not employed 
them, and therefore cannot express a personal opinion as to their merits. 
On general principles it may be assumed that they are effective, but 
also afford somewhat greater opportunity for infection from the rectal 
contents, since both hands are used and therefore must come into more 
intimate contact with the anal region than in Harris’s method. What¬ 
ever method of manual dilatation is employed, one should always suspect 
that it has given rise to lacerations. Accordingly, after delivery has 
been effected, the cervix should be freely exposed by the aid of a 







ACCOUCHEMENT FORCE 


433 


posterior retractor and tenaculum forceps and any serious tear imme¬ 
diately repaired. If such a precautionary inspection is made as a 
matter of routine, one will be surprised at the frequency and extent 
of deep cervical tears, and will learn to hesitate to make use of manual 
dilatation unless it is urgently necessary. 

Dilatation by Means of Champetier cle Ribes' Balloon. —Whenever 
haste is not a great consideration, this is the ideal method of accouche¬ 
ment force, and should he employed whenever possible. It is particu¬ 
larly indicated in cases of placenta previa, and will he referred to more 
fully under that head. The entire literature upon the subject was well 
reviewed by Burger in 1906. 

Instrumental Dilatation .—Various instruments have been devised to 



Fig. 348. —Vaginal Cesarean Section. Exposure of Cervix and Primary Incisions. 

effect the rapid and complete dilatation of the cervical canal, but to 
my mind none of them is satisfactory. 

Leopold, in 1902, introduced into Germany the use of BossFs power¬ 
ful dilator, which was first employed by its inventor in 1889. This 
consists of four heavy blades, arranged as compound levers and operated 
by a screw handle. Leopold was most enthusiastic concerning it, and 
his hearty indorsement led to its trial, in various modifications, in all 
parts of the world; but the final verdict is that it is a most dangerous 
instrument. 

I have had no experience with it; for, while there can be no doubt 
as to its dilating power, it seems to me that its sphere of usefulness 






434 INDUCTION OF ABORTION AND PREMATURE LABOR 


is very limited. If the cervix is undilated and rigid, its employment 
is unjustifiable; whereas, on the other hand, when the resistance of the 
internal os has already been overcome, equally satisfactory results may 
be obtained by other methods. Moreover, if cervical tears cannot be 
entirely avoided in manual dilatation, in which the resistance of the 
cervix can be accurately gauged by the operating hand, they must occur 
far more frequently when the dilating force is applied more or less 
blindly by means of a powerful steel compound lever. It is interesting 
to note that a similar instrument was devised in 1892 by Dr. H. S. 
Lott, of Salem, N. C., quite independently of Bosses invention. 

Deep Cervical Incisions .—When rapid delivery is urgently indicated 
in cases in which the cervical canal is obliterated but the external os 
not dilated, Diihrssen recommended, in 1890, that multiple incisions 
be made through the vaginal portion of the cervix, which are united 
by sutures after the completion of labor. The technic of the opera¬ 
tion is comparatively simple, as the incisions are readily made by means 
of scissors; but it has not been generally adopted, as there is no means 
of preventing further tearing of the incisions as the child is extracted, 
so that deep cervical lacerations frequently result, which may give rise 
to profuse hemorrhage and prove most difficult to repair. 

Vaginal Cesarean Section.—This operation, which is better designated 
as vaginal hysterotomy, was first described by Diihrssen in 1896, but 
did not come into general use for some years later on account of the 
polemical manner in which its inventor urged its claims. 

In my opinion it affords a satisfactory method for rapidly termi¬ 
nating pregnancy prior to the last month whenever the cervix is un¬ 
dilated and rigid, and is far superior to brutal attempts at manual or 
Instrumental dilatation. Unfortunately, it requires some surgical skill 
on the part of the operator, as well as specially devised specula, and 
the aid of several competent assistants, so that its use must be limited 
to hospital practice or to that of trained specialists. 

After the usual preparations for operation, a heavy traction suture 
is introduced through either side of the cervix. The latter is then 
drawn down as near as possible to the vulva, and a longitudinal in¬ 
cision made through the anterior vaginal wall from a little below the 
urethra to the external os (Fig. 348). The bladder is then separated 
from the anterior surface of the cervix and lower uterine segment by 
means of a finger covered by a piece of gauze. The first part of the 
separation is done by touch alone, but later a large retractor, with a 
blade measuring 5 X 12 centimeters, is introduced into the wound, after 
which the process is completed under the guidance of the eye, the 
bladder being drawn up behind the retractor, when the entire wall of 
the uterus, from the anterior lip of the cervix to the contraction ring, 
is freely exposed. The anterior wall of the cervix and lower uterine 
segment is then incised for a distance of about 10 centimeters by means 
of a pair of heavy scissors (Fig. 349), and, after removing the speculum, 
the hand is introduced into the uterus, ruptures the membranes, and 
turns the child. After its extraction and the expression of the placenta, 
the speculum is again introduced, and, by making the traction sutures 


VAGINAL CESAREAN SECTION 


435 


taut, the entire uterine wound is visible as a triangular opening. Its 
edges are then united from above downward by interrupted catgut 
sutures, which are introduced under the guidance of the eye, after 
which the vaginal incision is closed by a continuous catgut suture 
(Fig. 350). 

The anterior incision affords sufficient space for the extraction of the 
child up to the eighth month of pregnancy, but after that period a 
posterior incision is also necessary. In this event, the operation is 
begun by making a transverse incision in the posterior fornix at the 
cervical junction, and peeling off the peritoneum from the posterior 



Fig. 349.—Vaginal Cesarean Section. Incision of Anterior Uterine Wall after 

Separation of Bladder. 


wall of the cervix and lower uterine segment, which is then incised 
for a distance of 5 centimeters, after which the anterior wall is treated 
as has been described. The necessity for the double incision is readilv 
understood, when one recalls that the suboccipitobregmatic circumfer¬ 
ence of the fully developed head measures 32 centimeters, so that if 
only an anterior incision is made, it must measure 15 to 16 centimeters 
in length to permit the passage of the head without laceration of its 
upper end, which would necessitate opening the peritoneal cavity; 
whereas if the incisions are double, each requires to be only half so 
long. In the latter event, the posterior wound should be closed first. 

In competent hands vaginal hysterotomy permits the delivery of 
the child in a few minutes, no matter what the condition of the cervix, 





430 INDUCTION OF ABORTION AND PREMATURE LABOR 



and the entire operation requires thirty minutes or less for its com¬ 
pletion. Its advantages over manual or instrumental dilatation are that 
it leaves a clear-cut wound, properly united by sutures, in place of an 
irregular, deep, cervical laceration, which may extend into the lower 
segment, and which frequently cannot be properly repaired. If the 
incisions are made in the median line, the amount of hemorrhage is 
surprisingly small, and, if a suitable large retractor is employed, every 
step of the operation is readily visible. 

I consider that the difficulties which are sometimes encountered in 
its performance are usually due to two factors: first, that the speculum 


Fig. 350. —V aginal Cesarean Section. Laying of Sutures in Anterior Incision. 

Posterior Incision Already Sutured. 

employed is too small to give a suitable exposure of the field of opera¬ 
tion; second, that the incision is either too short or not in the mid-line 
of the uterus. In the latter event profuse hemorhage may occur, either 
as the result of laceration of the upper end of the incision during 
extraction of the head, or because the incision lies to one side of the 
mid-line. Diihrssen showed that there was a tendency to relaxation of 
the uterus after the operation, and advised that the cavity be packed 
with gauze as a prophylactic against such an accident. I believe that 
this is a wise precaution, and always introduce the pack before laying 
the sutures in the anterior wall. 

Diihrssen in 1909 stated that the technic of the operation could be 
simplified by introducing a medium-sized rubber balloon into the uterus. 






LITERATURE 


437 


which, after being filled tightly with sterile salt solution, is used as a 
tractor, the anterior wall of the cervix and lower uterine segment being 
incised over it until it slips out. 

A full account of the operation, together with a list of all the cases 
of vaginal hysterotomy reported up to 1905, will be found in Diihrs- 
sen’s article in WinckeTs “Handbuch der Geburtshiilfe.” My own 
favorable opinion is based upon a considerable number of operations; 
although I now employ it less frequently, for the reason that I treat 
patients suffering from eclampsia, which was the most usual indication 
for its use, much more conservatively than formerly. Peterson advo¬ 
cates it enthusiastically, and Winter reported that the mortality was 
only a trifle over 1 per cent, in 446 cases which he collected from the 
literature in 1909. 

LITERATURE 

Ahlfeld. 118 Falle von Einleitung der kiinstlichen Friihgeburt. Zentralbl. f. 
Gyn., 1890, xiv, 529-534. 

Bar. Contribution a P etude des indications del’accouchement premature arti- 
ficiel, etc. L’obstetrique, 1899, iv, 471. 

Bonnaire. De 1 ’accouchement methodiquement rapide. Presse med., 1909, Nos. 
66 and 67. 

Brouardel. L ’avortement. Paris, 1901. 

Burger. Die Bedeutung der Hystereuryse in der Geburtshiilfe. Archiv f. Gyn., 
1906, lxxvii, 485-556. 

Champetier de Ribes. De 1’accouchement provoque. Annales de gyn. et d’obst., 
1888, xxx, 401-438. 

Davis. Puerperal Pernicious Anaemia. Trans. Amer. Gyn. Soc., 1891, xviii, 173. 
Denman. An Introduction to the Practice of Midwifery. 7th ed., London, 
1823, 318. 

D ’Outrepont. Beobachtungen u. Bemerkungen. Gemeinsame Zeitschr. d. Ge- 
burtsk., 1828, ii, 549. 

Duhrssen. Ueber den Werth der tiefen Cervix- und Scheiden-Damm Einschnitte 
in der Geburtshiilfe. Archiv f. Gyn., 1890, xxxvii, 27-66. 

Der vaginale Kaiserschnitt. Berlin, 1896. 

Yaginaler Kaiserschnitt. WinckeUs Handbuch der Geburtshiilfe, 1905. 

Die neue Geburtshilfe und der praktische Arzt. Volkmann ’s Samml. klin. Vor- 
trage, 1909, No. 549-550. 

Edgar. Advantages of the Bimanual Dilatation of the Pregnant and Parturient 
Uterus. Tl-ans. Am. Gyn. Soc., 1906, xxxi, 108-115. 

Feiiling. Ein Fall von Chorea gravidarum. Archiv f. Gyn., 1874, vi, 137-139. 
Fieux. Procedes de provocation et de la terminaison artificielle rapide de 1 ’ac¬ 
couchement. Annales d’obst. et de gyn., 1901, lv, 409-450. 

Graefe. Ueber den Zusammenhang der perniciosen Anaemie mit der Graviditat. 
D. I., Halle, 1880. 

Guillemeau. De l’heureux accouchement des femmes. Paris, 1594. 

Harris. A Method of Performing Rapid Dilatation of the Os Uteri, etc. Amer. 
Jour. Obst., 1894, xxix, 37-49. 

Kleinwachter. Die kiinstliche Unterbrechung der Sclnvangerschaft, III. Aufl., 
1902. 

Krause. Die kiinstliche Friihgeburt. Breslau, 1855. 

Kronig. Wie we it soil das Recht des Kindes auf Leben bei der Geburt gewahrt 
werden? Monatsschr, f, Geb. u. Gyn., 1906, xxiii, 303-329. 


438 INDUCTION OF ABORTION AND PREMATURE LABOR 


Leopold (Busclibeck). Beitrag zur kiinstl. Fruhgeburt wegen Beckenenge, Ar- 
beiten aus der konigl. Frauenklinik in Dresden, 1893, i, 93-123. 

Leopold (Schoedel). E.rfahrungen iiber kiinstliche Frlihgeburten, eingeleitet 
wegen Beckenenge. Archiv f. Gyn., 1901, lxiv, 151-164. 

Zur sehnellen vollstandigen Erweiterung des Muttermundes mittels des Dila- 
torium von Bossi, etc. Zentralbl. f. Gyn., 1902, xxvi, 489-495. 

Lapage et Sainton. Accouchement provoque pour un cas de nevrite peripherique 
alcoholique. Comptes rendus de la soc. d’obst., de gyn. et de paed. de Paris, 
1901, iii, 93-99. 

Levin und Brenning. Die Fruchtabtreibung durch Gifte. Berlin, 1899. 

Lott. Instrumental Dilatation of the Cervix in the Last Months of Pregnancy. 
Amer. Gyn., 1903, iii, 295-299. 

Matthews. Pregnancy after Nephrectomy. Jour. Am. Med. Assoc., 1921, lxxvii, 
1634-1639. 

Mauriceau. Traite des maladies des femmes grosses, etc. 6me ed., 1721, 161. 

Pelzer. Ueber Einleitung der kiinstlichen Fruhgeburt. Zentralbl. f. Gyn., 1892, 
xvi, 35-36. 

Peterson. Indications for and Technique of Vaginal Ca3sarean Section. Surg. 
Gyn. and Obst., 1909, viii. 

Pinard. De 1’accouchement provoque. Annales de gyn. et d’obst., 1891, xxxv, 
1-16; 81-112. 

Indication de 1’operation Cesarienne consideree en rapport avec celle de la sym- 
physeotomie et de 1’accouchement premature artificiel. Annales de gyn. et 
d’obst., 1899, Iii, 81-117. 

Reifferscheid. Die Rontgentherapie in der Gynakologie. Leipzig, 1911. 

Siegemundin. Die konigl. preussische und Chur-Brandenb. Hof-Wehe-Mutter. 
Berlin, 1756, 216. 

Watson. Further Experience with Pituitary Extract in the Induction of Labor. 
Am. Jour. Obst. & Gyn., 1922, iv, 603-608. 

Williams. The Induction of Premature Labor and Accouchement Force in the 
First 5,000 Labors of the Obstetrical Department of the Johns Hopkins Hos¬ 
pital. Trans. Am. Gyn. Soc., 1906, xxxi, 316-333. 

Pernicious Vomiting of Pregnancy. Trans. Am. Gyn. Soc., 1905, xxx, 229-299. 

The Problem of Effecting Sterilization in Association with various Obstetrical 
Procedures. Am. Jour. Obst. and Gyn., 1921, i, 783-793. 

Williamson. The Induction of Premature Labor. Jour. Obst. and Gyn. Brit. 
Emp., 1905, viii, 252-271. 

Winter. Die Indicationen zur kiinstlichen Unterbrechung der Schwangerschaft, 
1918. 


CHAPTER XX 


FORCEPS 



Fig. 351. —Simpson’s Forceps, Qephalic Curve. 



The obstetrical forceps is an instrument designed for tlie extraction, 
under certain conditions, of the child when it presents by the head. It 
consists of two branches which cross one another, and are designated 
right and left, respectively, according to the side of the pelvis to which 
each corresponds. They are introduced separately into the genital canal 
and are articulated after being placed in position. Each branch is made 
up of four portions—the handle, blade, shank, and lock. 

The instruments vary considerably in size and shape, as will be seen 
when certain varieties of forceps are considered. The blades possess a 
double curvature — the 
cephalic and the pelvic 
—the former being 
adapted to the shape of 
the child’s head, the lat¬ 
ter to that of the birth 
canal. The blades are 
more or less elliptical 
in shape,, tapering 
toward the shank, and 
are usually fenestrated 
so as to allow of a firm 
hold upon the head. 

Certain authorities, however, prefer solid blades in the belief thai the} 
can be made less bulky. 

The cephalic curves should be such as to permit ’he head, to be 
grasped firmly, but without <wiious compression. The greatest distance 
between the two blades should not exceed 7.5 centimeters' (3 inches), 
when they are articulated. The pelvic curve corresponds more or less 
to the axis of the birth canal, but varies considerably in different 
instruments. When the foreceps is placed up on a plane surface, the 
tips of the blades should be about 8.8 centimeters ( 3 % inches) higher 
than the handles. The latter are connected with the blades by the shanks, 
which give the requisite length to the instrument. 

The two branches articulate at the lock, which vaiies wwidy m 
different instruments. The English type consists of a socket upon each 
branch, into which fits the shank of the other half of the instrument. 
This arrangement permits of ready articulation, but does not hold the 
blades firmly together. In the French lock a pivot is screwed into the 
shank of the left branch, while the right presents an opening which can 
I 439 


Fig. 352 .—Simpson’s Forceps, Pelvic C^RVE. 















440 


FORCEPS 



be adjusted to it, the screw being tightened after articulation. The 
German lock is a combination of the two, the shank of the left branch 
bearing a pivot with a broad, flat head, while the right is provided with 
a notch which corresponds to the pivot. When the instrument is 
properly articulated the handles should fall together in such a way as 
to be conveniently grasped by one hand of the operator. 

History.—Crude forceps were in 
use from an early period, several 
varieties having been described by 
Albucasis, who died in 1112; but, 


Fig. 353.—Loci: of English Forceps. 


Fig. 354.—Lock of Frecnh Forceps. 


as their inner surfaces were provided with teeth intended to penetrate 
the head, it is evident that they were intended for use only upon dead 
children. 

The true obstetrical forceps was devised in the latter part of the 
sixteenth, or the beginning of the seventeenth century, by a member of 
the Chamberlen family. The invention, however, was not made public 
at the tipie, but 
was preserved as 
a farnily secret 
through four gen¬ 
erations, and did 
not. bpoor .o gener¬ 
ally known until 
the early part of 
the eighteenth cen¬ 
tury. Prior to that 
time version had 
been the o n 1 y 
method which per¬ 
mitted the artificial 
delivery of an un¬ 
mutilated child, 
a n d accordingly 

wnen that operatw -vi* out of the question and delivery became im¬ 
perative, it was accomplished by means of hooks and crotchets, which 
usually led to the destruction of the child. Thus, before the invention 
of forceps, the use of instruments was synonymous with the death of 
the child, and frequently of the mother also, and tended to bring 
obstetrics into disrepute. 





Fig. 355.—Chamberlen’s Forceps. 




HISTORY 


441 


\\ illiam Chamberlen, the founder of the family, was a French physi¬ 
cian, who lied from France as a Huguenot refugee and landed at 
Southampton in 1569. He died in 1596, leaving a large family. Two 
of his sons, both of whom were named Peter, and designated as the 
elder and younger, respectively, studied medicine and settled in 
London. They soon became successful practitioners, and devoted a large 
part of their attention to midwifery, in which they became very pro¬ 
ficient. They attempted to control the instruction of midwives, and in 
justification of their pretensions claimed that they could successfully 
deliver patients when all others had failed. 

The younger Peter died in 1626 and the elder in 1631. The 
latter left no male children, but the former was survived by several 
sons, one of whom, born in 1601, was likewise named Peter. To dis¬ 
tinguish him from his father and uncle, lie is usually spoken of as 
Hr. Peter, as the other two did not possess that title. He)was well 
f educated, having studied at Cambridge, Heidelberg, and Padua, and 
on his return to London was elected a Fellow of the Royal College of 
Physicians. He was most successful in the practice of his profession, 
and counted among his clients many of the royal family and nobility. 
Like his father and uncle, he attempted to monopolize the control of 
the midwives, but his pretensions were set aside by the authorities. 
These attempts gave rise to a great deal of discussion, and many 
pamphlets were written as to the morality of women in labor being 
attended by men, which he answered in a pamphlet entitled “A A r oice 
in Ramah, or the Crv of Women and Children as Echoed Forth in the 
Compassions of Peter Chamberlen.” He was a man of considerable 
ability, and united at the same time some of the virtues of a religious 
enthusiast with many of the devious qualities of a quack. He died at 
AYoodham, Mortimer Hall, Essex, in 1683, the place remaining in the 
possession of his family until well into the succeeding century. For¬ 
merly he was considered the inventor of the forceps, but, as we now 
known, this view was incorrect. 

He left a very large family, and three of oons—Hugh, Paul, and 

John—became physicians, and. dg> J ^ special attention to the practice 
of midwifery. Of tb o Hugh (±630-1706) was the most im; ortant, 
and influential. Like his father, he possessed considerable ability, and 
at the same time took a practical interest in’politics. Some of his views 
not being in favor, he was forced to leave England, and while in Paris 
in 1673 attempted to sell the family secret to Mauriceau for 10,000 
livres, claiming that by its means he could deliver in a very few minutes 
the most difficult cases. Mauriceau placed at his disposal a rhachitic 
dwarf whom he had been unable to deliver, and Chamberlen, after several 
hours of strenuous effort, was likewise obliged to acknowledge his in- 
abilty to do so. Notwithstanding his failure, however, he maintained 
friendly relations with Mauriceau, and on returning home translated 
the latter’s book into English. In his preface he refers to the forceps 
in the following words: “My father, brothers, and myself (though none 
else in Europe as I know) have by God’s blessing and our own industry 




442 


FORCEPS 



Fig. 356. —Palfyn’s Forceps. 


attained to and long practiced a way to deliver women in this case 
without prejudice to them or their infants." 

Some years later he went to Holland and sold his secret to Roon- 
liuysen. Shortly afterward the Medico-Pharmaceutical College of Am¬ 
sterdam was given the sole privilege of licensing physicians to practice 
in Holland, to each of whom, under pledge of secrecy, was sold Cham- 
berlen’s invention for a large sum. This practice continued for a number 
of years, until Yischer and Van der Poll purchased and made public 
the secret, when it was found that the device consisted of one blade only 
of the forceps. Whether this was all that Chamberlen sold to R 0011 - 
huysen, or whether the Medico-Pharmaceutical College had swindled the 
purchasers, is not known. 

Hugh Chamberlen left a considerable family, and one of his sons 
—Hugh (1664-1728)—practiced medicine. He was a highly educated, 

respected, and philanthropic 
physician, and numbered 
among his clients members 
of the best families in Eng¬ 
land. He was an intimate 
friend of the Duke of Buck¬ 
ingham, and when he died the 

latter caused a statue to be erected in his honor in Westminster Abbev. 

%> 

During the later years of his life he allowed the family secret to leak 
out, and the instrument soon came into general use. 

For more than one hundred years it was believed that the forceps 
was the invention of Dr. Peter Chamberlen, but in the vear 1813 Mrs. 
Kembell, the housekeeper of a rich brewer who had purchased Dr. Peter 
Chamberleids country house, found in the garret a trunk containing 
numerous letters and instruments, among the latter being four pairs of 
forceps, together with several levers and fillets. As is evident from the 
drawings, the forceps were in different stages of development, one pair 
being hardly applicable to the living woman, while the others were 
useful instruments. Aveling, who has carefully investigated the matter, 
believes that the three ptrys of available forceps were used respectively 
bv the three Peters, and that iff eh nrobabilitv the first was devised 
by the elder Peter, son of the original William Probability is lent to 
this view by the fact that Dr. Peter, on one occasion, at least, spoke 
of the invention of his uncle. Sanger and Budin, who have also in¬ 
vestigated the subject, incline to the same belief. 

The forceps came into general employment in England during the 
lifetime of Hugh Chamberlen, the younger. The instrument was used 
by Drinkwater, who died in 1728, and was well known to Chapman and 
Giifard. The former, writing in 1733, says: “The secret mentioned 
by Dr. Chamberlen was the use of the forceps, now well known by all 
the principal men of the profession, both in town-and country.” 

In 1723 Palfyn, a physician of Ghent, exhibited before the Paris 
Academy of Medicine a forceps which he designated as mains de fer. 
It was crude in shape and did not articulate. In the discussion fol¬ 
lowing its presentation, De la Motte stated that it would be impossible 





HISTORY 


443 


to apply it to the living woman, and added that if by chance any one 
should happen to invent an instrument which could be so used and 
kept it secret for his own profit, he deserved to be exposed upon a 
barren rock and have his vitals 
plucked out by vultures, little 
knowing that at the time he 
spoke such an instrument had 
been in the possession of the 
Chamberlen family for nearly Fig. 357.— Smellie’s Short Forceps. 
one hundred years. 

The Chamberlen forceps was a short, straight instrument, which pos¬ 
sessed only a cephalic curve, and is perpetuated in the short or low 
forceps of to-day. It Avas used, with but little modification, until the 

middle of the eighteenth cen¬ 
tury, when Levret, in 1747, and 
Smellie, in 1751, quite inde¬ 
pendently of one another, added 
the pelvic curve and increased 
Fig. 358.— Short Forceps. tile length of the instrument, 

v Levret’s forceps was longer and 

possessed a more decided pelvic curve than that of Smellie, and it is 
from these two instruments that the long forceps of the present dav 
is descended—the long French forceps being the lineal descendant of 
the former, and that of Simpson of the latter. 





As soon as the forceps became public property it was subjected to 
various modifications, so that Mulder, ^ his atlas published in 1798. 
was able to give illustration* d nearly 100 varieties. Some idea of 
the desire to modify and im¬ 
prove the instrument may be 
gained by glancing at Wit- 
kowski’s Obstetrical Arsenal, 
in which are pictured several 
hundred forceps, which, after 
all, constitute only a small 
portion of those devised. Fig. 360.—Smellie’s Long Forceps. 

PoullePs interesting mono¬ 
graph contains an excellent historical sketch of the development oi the 

instrument. 

But, considering all the work done, it is surprising how little advance 
was made over the instruments of Levret and Smellie, until larnier 






444 


FORCEPS 


in 1877 clearly enunciated the principle of axis traction, which has 
since revolutionized our ideas upon the subject. 

Choice of Forceps. —Inasmuch as it would appear that in the past 
nearly every one interested in obstetrics has thought it necessary to 
attempt to modify the forceps, and to have an instrument bearing his 
own name, the young physician is likely to be embarrassed by the 
multitude from which he has to choose. Any properly shaped instru¬ 
ment will give satisfactory results, provided it be used intelligently, 
but for general purposes the ordinary Simpson forceps is probably the 
best, though, if one expects to do much obstetrical work, a Tarnier. 
axis-traction forceps becomes essential. Personally I always employ 
the latter, using the traction rods or not, according to circumstances, 
as I believe it better to become thoroughly familiar with one instrument 
than to have several for use under different conditions. 

The forceps should be entirely of metal, so that it can be readily 
sterilized by boiling. 

Functions of the Forceps. —This subject has been considered in de¬ 
tail by Chassagny. The forceps may be used as a tractor, rotator, com¬ 
pressor, dilator, lever, or irritator. 

Its most important function is traction, exercised for the purpose of 
drawing the head through the genital tract. In not a few cases, how¬ 
ever, particularly in transverse and posterior occipital presentations, its 
employment as a rotator is attended by most happy results. It should 
never be used primarily as a compressor, though of course it is impos¬ 
sible to make traction without subjecting the head to a slight degree of 
compression; but when it is desired to bring about a diminution in its 
size other instruments are more appropriate. 

Particularly in the past, certain authors advocated applying the 
forceps through a partially obliterated cervix, and assisting dilatation 
by traction upon the head. Such a procedure, however, is unjustifiable, 
for, when delivery becomes necessary under such conditions, the cervix 
* should be stretched manually, and forceps not applied until after dila¬ 
tation has bee At completed. 

In rare instances blade of the forceps may be employed as a 
lever—the vectis, although au present use is very seldom made of this 
function. Before the use of anestne&iu became general, great stress 
was laid on the so-called dynamic action of the forceps, by which is 
meant the irritation of the uterus wdiich follows its introduction. But 
at present this function is of no significance. 

Indications for the Use of Forceps. —Strictly speaking, the termina¬ 
tion of labor by forceps, provided it can be accomplished without too 
great danger, is indicated in any condition which threatens the life 
of the mother or child, and which offers a reasonable prospect of being 
relieved by delivery. On the part of the mother, such conditions are 
eclampsia, heart lesions attended by broken compensation, acute edema 
of the lungs, hemorrhage from premature separation of the placenta, 
intrapartum infection, or exhaustion. Whenever there is question of 
interference for the last-named condition, definite objective symptoms 
should be present, the condition of the pulse being of especial impor- 







INDICATIONS FOR THE USE OF FORCEPS 


445 


tance; whereas, on the other hand, but little weight should be attached 
to the statements of the patient. 

As regards the child, the operation may be called for by prolapse of 
the umbilical cord, premature separation of the placenta, undue pressure 
exerted upon the head, and especially by changes in the rhythm of its 
heart beat and the escape of meconium in vertex presentations. A 
foetal pulse falling permanently below 100, or exceeding 160 to the 
minute, indicates that the child is in danger and may perish if not 
promptly delivered. In vertex presentations the discharge of amniotic 
fluid tinged with meconium usually indicates interference with the 
placental circulation and imperfect oxygenation, manifesting itself by 
paralysis of the sphincter ani. In breech presentations, on the other 
hand, the escape of meconium is without significance, being due merely 
to pressure exerted upon the child’s abdomen. 

In practice, however, the maternal indications for the use of forceps 
may be considerably extended, and in many instances*the operation may 
be advisable in the case of women suffering from acute infectious dis¬ 
eases, heart lesions, and diseases of the respiratory tract, who must be 
saved as far as possible from the exhaustion incident to an unaided 
second stage of labor. Likewise, it is generally advisable to relieve the 
strain up =n a cicatrix resulting from a previous cesarean section. 

One of the most frequent indications is afforded by faulty con-" 
traction of the uterine or abdominal muscles, the forceps being utilized 
merely .to reenforce the insufficient vis a ter go. Eurthermore, in elderly 
primiparae, the amount of resistance offered by the perineum and the 
vaginal outlet may sometimes be so great as to oppose a serious obstacle 
to the passage of the child, even when the expulsive forces are normal. 
In the absence of disproportion, it is a good practical rule to apply 
forceps if advance does not occur after two hours of satisfactory second 
stage pains, but if the head is upon the perineum and no progress 
has been made for one hour in spite, of good pains^. it is usually not 
advisable to wait longer. At the same time it must be- insisted ^ n 
that the operation should never be performed to save* the physicians' 
time, nor to quiet the importunities of the patient’s fattiily, but only 
when distinctly indicated by the condition of the mother or child; so 
that, whatever the outcome may be, the conscience of the operator will 
be clear. 

De Lee takes a more radical position, as he believes that prolonged 
pressure of the foetal head against a more or less rigid perineum 
frequently results in serious injury to the cerebral tissues, and 
recommends the performance of what he designates as “the pro¬ 
phylactic forceps operation.” In this procedure, forceps are applied 

as soon as the head rests firmly upon the pelvic floor and has begun 
to part the pillars of the levator ani muscle; and is preceded by a 

deep lateral incision through the perineal and vaginal tissues, which 

extends into the levator ani if the disproportion promises to be great. 
He considers that the procedure adds greatly to the safety of the child, 
relieves the patient from a considerable part of the strain incident to 
the second stage of labor, and leaves her genitalia in such condition 




446 


FORCEPS 


that the occurrence of outlet relaxation in the future is reduced to a 
minimum. In his skillful hands, these objects are no doubt accom¬ 
plished, but even he recommends restricting' the operation to the 
trained specialist. For my part, 1 am confident that the results would 
be disastrous were his suggestion generally adopted. 

The folloiving conditions must be fulfilled before forceps can be 
applied with safety: (1) The child must present correctly; (2) the 
cervix must be fully dilated or dilatable; (3) the membranes must be 
ruptured; (4) the head of the child must be neither too large nor too 
small; and (5) the pelvis must not be too contracted. 

The child should present by the vertex or face, and an accurate 
diagnosis be made as to the position and variety, forceps not being 
available when the chin is directly posterior. The forceps is not ap¬ 
plicable to shoulder presentations, nor is it intended to be applied to 
the breech. Generally speaking, it should not be employed in brow 
cases until after conversion into a vertex or face presentation has been 
brought about. 

The cervix must always be completely dilated before the application_ 
of forceps, offering a diameter of from 9 to 10 centimeters. Of course 
it is possible to apply the blades through a canal measuring only 4 or 
5 centimeters, but in such circumstances the cervical ring offers marked 
resistance, and, if the head be dragged through it, deep tears may re¬ 
sult, which may also implicate the lower uterine segment. Accordingly, 
if prompt delivery becomes imperative when the cervix is only partially 
dilated, its complete dilatation should be effected manually before for¬ 
ceps are applied. On the other hand, if the head is only partially 
engaged, or is floating above the superior strait, delivery is best effected 
after podalic version provided the uterus is not too tightly contracted 
and serious disproportion does not exist. 

The membranes should always be ruptured before applying forceps, 
for, if il r intervene, the grasp upon the head is not so firm, and, what 
i» more important, traction upon them may occasionally bring about 
premature separation of the placenta. 

Before applying forceps, particularly when engagement has not yet 
occurred, the size of the head should be determined as accurately as 
possible, for if it be unduly large, as in an excessively developed or 
hydrocephalic child, it cannot pass the superior strait. On the other 
hand, if it be abnormally small, it cannot be properly grasped, since 
the blades will slip off when traction is made. Accordingly, the em¬ 
ployment of forceps is questionable when the foetus is small or mac¬ 
erated. 

Generally speaking, contracted pelvis presents an absolute contra¬ 
indication to the application of forceps; for, if the contraction be 
marked, it will be impossible to drag the head through the pelvis, and 
the employment of brute force may result in the death of the child and 
severe injuries to the mother. On the other hand, when the contraction 
is but slight, and especially when the head is firmly engaged in the 
upper part of the pelvic cavity, the tentative applicr tion of forceps 
may be justifiable. l T nder such circumstances a few tiactions of mod- 





PREPARATIONS FOR OPERATIONS 


447 


erate intensity should be made; if the head follows they should be con¬ 
tinued, hut if not the forceps should he removed and delivery effected 
in some other manner. 

Preparations for Operation.—When the application of forceps be¬ 
comes necessary, either in the interests of the mother or child, the 
physician should inform a responsible member of the family of his 






Fig. 361. 

Robb’s Leg-Holder. 


decision. It is not advisable to inform the patient until the prepara¬ 
tions for operation are completed. 

W henever possible, the patient should be placed upon a table of 
suitable height, as ordinary beds are too low and too soft for con¬ 
venience. Anesthesia should always be employed, and whenever practic¬ 
able its administration should be intrusted to a competent assistant, 



rather than to the nurse or some member of the family, since in the 
latter case a large part of 
the obstetricians attention 
must of necessity be de¬ 
voted to watching the gen¬ 
eral condition, instead of 
being concentrated upon 
the operation. 

Wh e n anesthesia is 
complete, the patient’s but¬ 
tocks should be brought to 
the edge of the table, and 
her legs held in position 
by an appropriate leg- 
holder, which is particu¬ 
larly convenient in private 
practice, as it enables one 
to dispense with assistants 
for holding the legs. The 

patient is then prepared for operation, as is described on page 417. 

Except when the outlet is greatly relaxed, it is advisable to dilate it 
manually before beginning the operation; as by so doing, the liability 
to laceration is decreased, and less powerful traction is necessary. 
For this purpose, the hand is freely lubricated, and preliminary dila¬ 
tation is effected by making downward and lateral traction with two 
finders. Then, the fingers, being arranged in the form of a cone, are 


Fig. 362. —Diagram showing Position of Head in 
Various Forceps Operations. 














448 


FORCEPS 





Fig. 363. —Forceps Correctly Applied along occi¬ 
pitomental Diameter, Pelvic Curve towards 
Occiput. 


iven a rotary motion and slowly introduced into the vagina, gradually 
dilating it until the closed list can pass the vulval outlet with ease. 

I regard this 
“ironing out” 
of the vaginal 
outlet and pel¬ 
vic floor as so 
essential that I hold that 
forceps should not be ap¬ 
plied until it has been 
effected. 

Application of For¬ 
ceps. —Forceps operations 
are designated as low, 
mid, high, and floating, 
according to the position 
of the head. When the 
presenting part rests up¬ 
on the perineum, or lies 
well below the line join¬ 
ing the ischial spines, we 
speak of low forceps; 
when it presents at 
or just above the 
ischial spines, mid for¬ 
ceps; when the head has 
partially descended into 
the pelvic canal, but its 
greatest circumference 
has not passed the su¬ 
perior strait, high for¬ 
ceps; and when it is 
movable above 
the pelvic brim 
the operation is 
termed forceps up¬ 
on the floating 
head. 

The low forceps oper¬ 
ation usually offers but 
little difficulty, except in 
certain funnel-shaped 
pelves, and may be un¬ 
dertaken upon compara¬ 
tively slight indications. 
The mid operation is 
more difficult, but not 
often excessively so. On the other hand, the high operation is 
always difficult, and should not be attempted unless imperatively de- 


Fig. 364. —Forceps Correctly Applied along Occi¬ 
pitomental Diameter, Pelvic Curve towards 
Face. 






fefe 


freely 


Fig. 365. —Forceps Applied to Face along Occipito¬ 
mental Diameter. 











APPLICATIONS OF FORCEPS 449 

manded by the condition of the mother or child. Forceps upon the 
oatmg head is a most serious procedure, and is very rarely indicated. 



Fig. 366. —Forceps Applied Obliquely over Brow and Mastoid Region. 



Fig. 367. —Showing that when one Blade is Applied over Occiput and Other over 

the Face, Forceps cannot be Locked. 




Fig. 368. —Showing Extension of Head when One Blade is Applied over Brow and 
Other over Occiput, explaining Tendency of the Instrument to Slip Off. 


Generally speaking, the fact that the head is not engaged indicates 
some disproportion between it and the superior strait, so that the 












450 


FORCEPS 




Fig. 369.—Low Forceps; Introduction of 
Left Blade to Left Side of Pelvis. 


operation should not be thought 
of until accurate information as 
to the size of both is available. 
Moreover, in those cases in which 
there is no serious disproportion, 
delivery can usually be accom¬ 
plished more safely and rapidly 
by version. 

The forceps is so constructed 
that its cephalic curve is best 
adapted to the sides of the child's 
head, the biparietal diameter cor¬ 
responding to the line of greatest 
distance between the blades. 
Consequently, the head is grasped 
in an ideal manner only when 
the long axis of the blades cor¬ 
responds to the occipitomental 
diameter, the fenestra including 
the parietal bosses and the tips 
lying over the cheeks, while the 
concave margins of the blades 
look toward either the occiput or 
the face. With such a grasp the 
forceps obtains a firm hold and cannot slip off, and traction can be 
made in the most advantageous manner. On the other hand, when 
the forceps is applied obliquely with 
one blade over the brow and the 
other over the opposite mastoid 
region, the grasp is less secure, and 
the head is exposed to injurious 
pressure. If one blade is accurately 
applied over the face and the other 
over the occiput, the instrument can¬ 
not be locked, while, if the blade 
over the face is slipped down so as 
to permit articulation, the grasp is 
very insecure and each traction 
tends to extend the head (see Figs. 

367 and 368). 

For these reasons, then, the for¬ 
ceps should be applied, when pos¬ 
sible, directly to the sides of the 
head along its occipitomental or 
jugoparietal diameter. This is 
known as the cephalic, in contra¬ 
distinction to the pelvic application. 

The former was recommended by Smellie and Baudelocque, but, as it 
is more difficult than the latter, it fell into disuse, and was not gen- 


Fig. 370.— Low Forceps; Left Blade in 
Place. 

















APPLICATIONS OF FORCEPS 


451 




erally practiced until Pinard, 

Farabeuf, and Yarnier dem¬ 
onstrated the inestimable ad¬ 
vantages which it possesses 
over the pelvic application. 

In the pelvic application, the 
left blade is applied to the 
left and the right blade to the 
right side of the mother's 
pelvis, no matter what the 
presentation, consequently the 
head is grasped satisfactorily 
only when the sagittal suture 
is directed anteroposteriorly. 

An accurate idea of the 
exact position of the head is 
essential to the cephalic ap¬ 
plication. With the head low 
down, this can usually be ob¬ 
tained by examining with two 
fingers; but when it is higher 
up an absolute diagnosis can 
be made only by locating the 
'posterior ear, which necessi¬ 
tates the introduction of the 
entire hand into the vagina. 

This, of course, requires pro¬ 
found anesthesia, and is therefore practicable only just before introduc¬ 
ing the forceps. After locating 
the ear, the examining hand is 
not removed, but remains in 
place to serve as a guide for the 
introduction of the first blade, 
which should be applied over the 
posterior ear, no matter whether 
it be the right or left. This 
rule admits of exception in two 
instances only—namely, when 
the head is resting upon the 


Z J C /<yv <7 C 


Fig. 371.—Low Forceps; Left Blade in Place, 
Introduction of Right Blade. 




sagittal 


Fig. 372.—Low Forceps; Instrument in 
Place and Articulated. 


perineum, when the 
suture usually extends antero¬ 
posteriorly, or when it is mov¬ 
able at the pelvic brim. Faulty 
diagnosis frequently results in 
an improper application of for¬ 
ceps, and is a leading factor in 
converting what should lie a 
simple procedure into a serious 
and difficult operation. 































45 '2 


FORCEPS 


Forceps Delivery with the Head at the 1 ulva. With the head in 
this low position, the obstacle to delivery is usually due to insufficient 

expulsive force or to abnormal resistance on the part of the perineum. 

In such circumstances 

the sagittal suture usual¬ 
ly occupies the antero¬ 
posterior diameter of the 
pelvic outlet, with the 
small fontanel directed 
toward either the sym¬ 
physis pubis or the con¬ 
cavity of the sacrum. In 
either event the forceps, 
if applied to the sides of 
the pelvis, will grasp the 
head in an ideal manner. 
Accordingly, the left 
blade is introduced to the 
left and the right blade 
to the right side of the 
pelvis, the mode of pro¬ 
cedure being somewhat 
as follows: Two fingers of the right hand are passed into the left 
and posterior portion of the vulva and carried up the vagina past the 




Fig. 374. —Low Forceps; Upward Trac- Fig. 375.—Low Forceps, Extreme Up- 
tion. ward Traction. 


margins of the external os. The handle of the left branch is then 
seized between the thumb and two fingers of the left hand—just as in 
holding a pen—and the tip of the blade is gently passed into the' 
vagina along the palmar surface of the fingers of the right hand which 























APPLICATIONS OF FORCEPS 


453 


serve as a guide. As it is introduced, the handle is at first held almost 
vertically, but, as the blade adapts itself to the head, it is depressed, 
so that it eventually takes a horizontal position. The guiding fingers 
are then withdrawn, and the handle is left to itself or held by an 



Fig. 376.—Low Forceps; Occiput Directly Posterior; Horizontal Traction 

(Farabeuf and Varnier). 


assistant. In the same manner, two fingers of the left hand are then 
introduced into the right and posterior portion of the birth canal to 
serve as a guide for the right blade, which is held in the right hand 



Fig. 377— Low Forceps; Occiput Directly Posterior; Upward Traction 

(Farabeuf and Varnier). 


and introduced into the vagina. The guiding fingers are now removed 
and all that remains to be done is to articulate the branches. Usuall) 
they lie in such a manner that they can be locked without difficulty; but 
when this cannot be done, first one and then the other blade should he 












454 


FORCEPS 


gently moved until the handles are brought into such a position as to he 
articulated with ease. 

When this has been accomplished, an examination is made to ascer¬ 
tain whether the blades have been correct] y applied, or whether they 
inclose the lips of the cervix. In the latter case the forceps should 
be loosened and reapplied. When it is certain that the blades are 
satisfactorily placed, the handles are seized with one hand and gentle 
intermittent traction is made in a horizontal direction until the peri¬ 
neum begins to bulge. As soon as the vulva begins to be distended 
by the occiput, the handles are gradually elevated, and eventually come 
almost in contact with the abdomen of the patient as the parietal bosses 
emerge. During the latter maneuver, the four fingers should grasp 



Fig. 378. —Mid Forceps; Hand in Vagina Fig. 379. —Mid Forceps; Introduction 
Seeking Posterior Ear. of First Blade. 


the upper surface of the handles and shanks, while the thumb upon 
their lower surface exerts the necessary force. 

In delivering the head nature's method should be simulated as closely 
as possible, and the minimum amount of force employed. Accordingly, 
traction should be made intermittently, the head being allowed to recede 
in the intervals, as in spontaneous labor. Except when urgently indi¬ 
cated, it should he extracted very slowly, so as to give time for proper 
stretching and dilatation of the perineum, which in primiparous women 
cannot lie satisfactorily accomplished in less than from ten to fifteen 
minutes. 

When the vulva is well distended by the head and the brow can 
be felt through the perineum, the mode of completing delivery varies. 
I usually do so with the forceps in place, holding that in this way I 
have the greatest control over the advance of the head. Others, on the 
contrary, contend that the thickness of the blades adds to the distention 
of the vulva and thus increases its liability to laceration. For this 























APPLICATIONS OF FORCEPS 


455 



reason, they remove the forceps and complete delivery by Ritgeffis 
maneuver slowly expressing the head by making upward pressure upon 
the brow through the posterior portion of the perineum. It is a matter 
of indifference which procedure is followed, but I prefer the former. 
Occasionally the forceps are removed too soon, and in this event Ritgenfs 
maneuver proves a tedious and inelegant procedure. 

When the occiput lies directly posteriorly, traction should be made 
in a horizontal direction until the forehead or root of the nose engages 
under the symphysis, after which 
the handles should be slowly 
elevated, until the occiput slowly 
emerges over the anterior margin 
of the perineum, and then, by 
imparting a downward motion to 
the instrument, the forehead, 
nose, and chin will successively 
emerge from the vulva. This ex¬ 
traction is more difficult than 
when the occiput is anterior, and, 
owing to the greater distention of 
the vulva, perineal tears are more 
liable to occur. 

Low and Mid Forceps Opera¬ 
tions .—When the head lies above 
the perineum, the sagittal suture 
usually occupies an oblique or 
transverse diameter of the birth 
canal. In such cases the forceps 
should always be applied to the 
sides of the head. This is best 
accomplished by introducing two 
or more fingers into the vagina 
sufficiently deeply to feel the pos¬ 
terior ear, over which, no matter 
whether it be the right or left, 
the first blade should be applied. 

In left occipito-anterior positions the entire right hand, introduced 
into the left posterior segment of the pelvis, should locate the posterior 
ear, and at the same time serve as a guide for the introduction of the 
left branch of the forceps, which is held in the left hand and applied 
over the posterior ear. The guide hand is then withdrawn, when the 
handle may be held by an assistant or left to itself, as the blade will 
usually retain its position without difficulty. 

Two fingers of the left hand are then introduced into the right 
and posterior segment of the birth canal, no attempt being made to 
reach the anterior ear, which lies in the neighborhood of the right 
iliopectineal eminence. The right branch of the forceps, held in the 
right hand, is then introduced along the left hand as a guide. After 
its introduction it still remains to apply it over the anterior ear of 


Fig. 380.—Mid Forceps; Introduction of 
Second Blade. 





















456 


FORCEPS 



the child. This is accomplished by gently rotating it anteriorly until 

it comes to lie directly op¬ 
posite the blade which was 
first introduced. The two 
branches being now articu- 
ulated, one blade of the for¬ 
ceps occupies the posterior 
and the other the anterior ex- 


Fig. 381. Fig. 382. 

Figs. 381, 382. —Mid Forceps; Instrument Applied in L. O. A. 




tremity of the left diameter (see Figs. 381 and 382). 

In the right positions, 
the blades are introduced in 
a similar manner but in j 
opposite directions, for in 
this case the right is the 
posterior ear, over which the 
first blade inserted must ac¬ 
cordingly be placed. It . 
should, however, be remem¬ 
bered that after the blades 
have been applied to the 
sides of the head the left 
handle and shank will lie 
above the right, and con¬ 
sequently the forceps w T ill 
not immediately articulate, 
but this difficulty can be 


Fig. 383. Fig. 384. 

Figs. 383, 384. —Mid Forceps; Instrument Applied in R. O. T. 

readily overcome by rotating the former around the latter so as to bring 
the lock into proper position (Fig. 399). 

































APPLICATIONS OF FORCEPS 


457 


If the occiput is 
in a transverse posi¬ 
tion, the forceps is 
introduced in a 
similar manner, the 
first blade being ap¬ 
plied over the pos¬ 
terior ear, and the 
second being rota¬ 
ted anteriorly until 
it comes to lie op¬ 
posite the first. In 
this case one blade 
lies in front of the 
sacrum and the 
other behind the 
symphysis (Figs. 

383 and 384). 

Whatever the original position of the head may be, delivery is ef¬ 
fected by making traction obliquely downward until the occiput appears 
at the vulva, the rest of the operation being completed in the manner 




Fig. 386. —Showing Manner of Making Traction in Mid Forceps Operation. 






















458 


FORCEPS 


already described. When the occiput is obliquely anterior, it gradually 
rotates spontaneously to the symphysis pubis as traction is made. But 
when it is directed transversely, in order to bring it to the front, it 
is sometimes necessary to impart a rotary motion to the forceps while 



Fig. 387. Fig. 388. 

Figs. 387, 388. —Diagrams showing Rotation of Obliquely Posterior Occiput to 

Sacrum and Symphysis Pubis Respectively. 




making traction. The direction in which this is to be made varies, of 
course, according to the position of the occiput, rotation from the left 
side toward the middle line being necessary when the occiput is directed 
toward the left, and in the reverse direction when it is directed toward 
the right side of the pelvis 
(see Figs. 383, 385). 

In making traction, be¬ 
fore the head appears at 
the vulva, one or both 
hands may be employed 
according to the amount 
of force required. When 
the Simpson forceps are 
used, one hand grasps the 
handles of the instrument, 
while the fingers of the 
other are hooked over the 


Fig. 390. 


Figs. 389, 390.—Showing Inversion of Forceps when Anterior Rotation from an 

R. O. P. Position is Completed. 


transverse projection at their upper ends. Care must be taken not to 
employ too much force. To avoid this error the operator should stand 
or sit with his arms flexed and the elbows held closely against the 























APPLICATIONS OF FORCEPS 


459 


thorax, as it is not permissible to make use of the body weight, and 
still less to brace the feet against the.side of the bed (Fig. 386). 

Application of Forceps in Obliquely Posterior Positions .—Prompt 
delivery may become necessary when the small fontanel is directed 
toward one or other sacro-iliac synchondrosis—namely, in R. 0. P. and 
L. 0. P. presentation. When interference is required in either of these, 
the head usually lies at or below the level of the ischial spines, and is 
often imperfectly flexed. 

In many cases, when the hand is introduced to locate the posterior 
ear, the occiput will rotate spontaneously to a transverse position, and 
delivery by forceps is then accom¬ 
plished, as already described. If, 
however, rotation does not occur, 
the head should be seized, with 
four fingers over its posterior and 
the thumb over its anterior ear, 
and an attempt made to rotate 
the occiput to a transverse posi¬ 
tion. This can usually be accom¬ 
plished with ease, and occasionally 
even rotation to an anterior posi¬ 
tion can be brought about. The 
forceps is then applied as de- 




Figs. 391, 392. —Scanzoni’s Maneuver; First Application of Forceps. 


scribed above. In other cases, after manual rotation has been effected, 
the head slips back into its original position before the forceps 
can be applied. To obviate this difficulty, De Lee recommends seizing 
the scalp by means of a pair of bullet forceps and holding the head 
in the desired position until the blades are adjusted. 

In a small proportion of cases, however, manual rotation cannot be 
effected, and in such cases the forceps must be applied with the occiput 
still' directed obliquely posterior. In these circumstances, if the instru¬ 
ment be.applied to the sides of the head, or even obliquely, and it is 
attempted to effect delivery by making traction in the usual manner, 
great difficulty is experienced and powerful traction usually fails to 
bring about the desired result. It is this experience which has given 
rise to the great dread in which these presentations are generally held, 
and it is a very good practical rule, whenever unexpected difficulty 
















460 


FORCEPS 




Fig. 395. Fig. 396. 

Figs. 395, 396. —Scanzoni’s Maneuver; showing Rotation to Anterior Position 

Forceps Inverted. 

and also more likely to give rise to deep perineal tears. 


\ Z 0 £ A" W 0 <7P, 

' s&cl. 


Fig. 393. Fig. 394. 

Figs. 393, 394. —Scanzoni’s Maneuver; showing Rotation to Transverse Position. 


pelvic outlet. This can he accomplished by rotating the occiput 
by means of the forceps, either through an arc of 45 degrees to the 
hollow of the sacrum, or 


through 


one of 135 de¬ 


grees 


to the symphysis 
pubis (Figs. 387 and 
388). The latter is more 
advantageous, for the 
reason that delivery in 
the directly posterior 
position is more difficult 


is experienced in delivering 
what is apparently a simple 
anterior presentation, to think 
of the possibility of a mistake 
in diagnosis and to reexamine 
the patient. It will then gen¬ 
erally he found that a mistake 
lias been made, and that the 
small fontanel lies in the 
neighborhood of one or other 
sacro-iliac synchondrosis. 

In order to effect delivery, 
the head must be rotated so as 
to bring its sagittal suture 
into coincidence with the an¬ 
teroposterior diameter of the 





































APPLICATIONS OF FORCEPS 


461 



Unfortunately, when it is desired to rotate the occiput forward, the 
forceps, if applied to the sides of the head with the pelvic curvature 
directed upward, becomes inverted by the time rotation is completed, 
so that the pelvic curve then looks posteriorly, and an attempted de¬ 
livery with the instrument in this position is liable to cause serious 
injury to the maternal soft parts (Figs. 389 and 390). In order to 
avoid this, it is best to remove and reapply the instrument, as described 
below. If one wishes to avoid this double application, the head may 
be seized obliquely with one blade over the anterior brow and the other 
over the posterior mas¬ 
toid region; but this is 
not advisable, however, 
as the procedure is more 
difficult for the operator 
and far more dangerous 
for the child. 

The double appHca- 
tion of forceps, which 


Fig. 397. Fig. 398. 

Figs. 397, 398. —Scanzoni’s Maneuver; Second Application of Forceps. 


was recommended by Scanzoni many years ago, has given such excellent 
results in my hands that I employ it to the exclusion of all other 
methods when the occiput cannot be rotated manually from its obliquely 
posterior position. It, however, is rarely necessary, and in my service 
is employed in only 1 or 2 per cent, of all obliquely posterior occipital 
presentations. As the right posterior variety is much the more frequent, 
I shall describe in detail the steps of the operation. 

In the first application the blades are applied to the sides of the 
head with the pelvic curve looking toward the face of the child, whereas 
in the second manipulation it looks toward the occiput. For the first 
application (Figs. 391 and 392) the right hand is passed into the left 
posterior segment of the genital tract, and the posterior (right) ear 
sought for. Over it the left blade is applied. This is held in position 
by an assistant, while the operator’s left hand is passed into the right 
side of the vagina controlling the introduction of the right blade, which 
is then rotated anteriorly until it comes to lie opposite the blade first 
introduced. The forceps is then locked, its blades now occupying the 
left and the sagittal suture the right oblique diameter of the pelvis. 



















462 


FORCEPS 


Downward traction is then made, and at the same time a rotary motion 
is imparted to the forceps when the head slowly descends and rotates 
to a right transverse, and later on when it impinges upon the pelvic 
floor to an obliquely anterior position (see Figs. 393 to 396). 

The forceps having become inverted, must be taken off, and reapplied 
in the usual manner to the head, which now occupies a right anterior 
position, when delivery is readily accomplished. Some difficulty may 
arise in bringing about proper articulation, since the handle of the 

left branch lying above 
the right cannot be 
locked, but this can 

' i 

be readily overcome 
by rotating the former 
around the latter so as 
to bring the lock into 
proper position (see 
Fig. 399). In left 
positions the blades 
are applied in a simi¬ 
lar manner, but in the 
reverse direction. 

By this method I 
have been able to de¬ 
liver many women 
with ease after the 
usual methods had 
failed. Indeed, my 
experience has been so 
satisfactory that I 
have ceased to dread 
occipitoposterior pres¬ 
entations, and now 
regard them with 
equanimity feeling 
that delivery can be 
readily and safelv ef- 
fected when necessarv. Bill, of Cleveland, is an enthusiastic advocate 
of a similar procedure, except that he rotates the head before beginning 
to make traction. 

Kielland, of Christiania, in 1916 described a forceps with narrow, 
somewhat bayonet shaped blades, which he claims can readily be applied 
to the sides of the head, and surpasses all other models as a rotator. 
He introduces the anterior blade first with its cephalic curvature directed 
forward, and, after it has entered sufficiently far into the uterine cavity, 
he turns it through 180 degrees in order to adapt the cephalic curvature 
to the head. I have had no experience with it, but it has been ex¬ 
tensively employed in Germany with varying results—some considering 
it an ingenuous and useful invention, while others hold that it possesses 
no advantages over the usual types of forceps. The critique of Fink 



Fig. 390.—Scanzoni’s Mantever; Showing Difficulty 
in Articulating Blades in Second Application of 
Forceps. 
















APPLICATIONS OF FORCEPS 


463 


affords an admirable resume of the literature upon the subject up to 
1923. 

To avoid the necessity of constantly bearing in mind which is the 
left and which the right branch of the forceps, it is a good practical 
rule for a beginner, after having made an accurate diagnosis of the 
position of the head, to articulate the forceps and to hold them before 
the vulva of the patient. In this way he readily appreciates how they 
should be applied, and which blade is to go over the posterior ear. 

High Forceps .—As has already been said, the high are much more 
difficult that the mid or low forceps operations, and should not be 
undertaken unless urgent indications are present. If the head be well 
engaged, the forceps should be applied as in the mid or low operation, 
except that, owing to the more elevated position of the head, the blades 
must be introduced for a greater distance into the genital tract before 
being applied. 

On the other hand, if the entire head lies above the superior strait, 
or only a small segment of it is engaged, the use of forceps is usually 
contra-indicated, as failure of engagement generally indicates the exist¬ 
ence of disproportion between the head and the pelvis. If, however, the 
operation appears to be called for, and the sagittal suture lies transversely, 
as it usually does if the pelvis is contracted, the forceps should be applied 
obliquely, one blade over the mastoid and the other over the opposite 
brow. To my mind this is the only condition in which the interests 
of the mother and child are not best served by the cephalic application; 
but in these circumstances, the blades of the forceps, if applied to the 
sides of the head, will occupy the extremities of the eonjugata vera, 
and still further increase the disproportion. More important still is the 
fact that the posterior blade bridges over the anterior concavity of the 
sacrum and thus prevents the head from entering the pelvic cavity, 
thereby defeating the very purpose for which the operation would be 
undertaken (Fig. 400). 

Axis-traction Forceps .—With the ordinary long forceps, the high and 
occasionally even the mid operation is comparatively difficult, strong 
traction being necessary to effect delivery. This is due to the fact that, 
owing to the shape of the birth canal and of the forceps, it is impos¬ 
sible to exert traction directly in the axis of the superior strait. The 
latter, as we know, would, if continued downward, pass through the 
lower portion of the sacrum; but, owing to the presence of the perineum, 
the extremity of the sacrum and the coccyx, it is impossible to depress 
the handles of the forceps sufficiently to permit of traction in the desired 
direction. As a consequence, a very considerable part of the force exerted 
is wasted in dragging the head against the symphysis, instead of bring¬ 
ing it downward. Thus, Tarnier pointed out that a force of 40 pounds 
employed in a high forceps operation would be resolved into two forces— 
one of 30 pounds and the other of 26 pounds—the former being in the 
axis of the superior strait and serving to bring about descent, whereas 
the latter would be directed against the symphysis pubis and would not 
only be wasted, but would actually retard delivery. 

This defect in the forceps has long been recognized. Saxtorph, in 


464 


FORCEPS 


1772, suggested that delivery could be greatly facilitated by attaching a 
lac to the eye of each blade and making traction upon these, as well 
as with the handles. He also showed that a similar result might be 
attained by making strong downward pressure with one hand in the 
neighborhood of the lock, while the other was used for traction. r J his 
maneuver is variously attributed to Osiander and Pajot, but was recom¬ 
mended by Saxtorph forty-four years before either was born (Fig. 
402). 



Fig. 400.—Diagram Showing Defect of Cephalic Application of Forceps When 
Head is at Superior Strait; Black Line Indicating Direction of Actual and 
Dotted Line that of Ideal Traction (Farabeuf and Varnier). 


Hermann, of Berne, in 1844, was the first to attempt to overcome 
the difficulty by devising an axis-traction forceps, his crude instrument 
being shown in Fig. 403. Hubert, of Louvain (1860), found that in 
certain cases, by turning the handles downward, he could make traction 
along the axis of the superior strait, his instrument giving ideal results 
when the sagittal suture was directed anteroposteriorly, but being useless 
in all other positions. Morales (1871) added a perineal curve to the 
forceps, but his invention possessed the same disadvantages as that of 
Hubert. None of these instruments were of much practical value, but 
they served to emphasize the faults of those in general use. 

Finally, in 1877, Tarnier solved the problem by attaching a rod to 
each blade and connecting them with a traction bar. His original forceps 
possessed a definite perineal curve, and was very cumbersome. The 
importance of his invention was soon recognized, and obstetricians 
throughout the world promptly attempted to improve upon it; so that 
at present one or more modifications of axis-traction forceps, each desig¬ 
nated by the name of the modifier, are to be found in every large city. 








APPLICATIONS OF FORCEPS 


465 


The modification devised by Milne Murray enjoys great popularity in 
Great Britain, but to my mind it is inferior to the last Tarnier model. 
Tarnier himself, not considering his original forceps satisfactory, 

F 



Fig. 401. —Tarnier’s Diagram; Showing Defects of Ordinary Forceps. 

A E C, line of actual traction ; A D B, line of desired traction; ASF, force wasted 

against symphysis pubis. 


continued to make changes and improvements, so that before his death 
he had devised an instrument which leaves little to be desired. It is 
practically a long French forceps without a perineal curve, provided 


Fig. 402.—Saxtorph Maneuver. 



with short, detachable traction-rods, one of which is inserted just beyond 
the eye of each blade. AVhen not in use, these are held in place by a 
pin upon the under surface of the shank, from which they can be readily 





466 


FORCEPS 





Fig. 403. 

Hermann’s Forceps. 


Fig. 404. —Hubert’s Forceps. 


freed, and attached by their free ends to a traction attachment which 
terminates in a handle-bar which can be grasped by one or both hands 
(see Figs. 407 and 408). 

With this device, traction can be made almost in the axis of the 

superior strait, and, 
owing to the pres¬ 
ence of numerous 
joints in the trac¬ 
tion attachment, 
the instrument can 
be used in any po¬ 
sition. The handles 
of the forceps mere¬ 
ly serve to indicate 
the direction in 
which traction 
should be made, the 
force being applied 
to the handle-bar, 
which is held hori¬ 
zontally no matter 
what the position 
of the blades may 
be, the traction- 
rods being kept 
about one centi¬ 
meter beneath the 
handles (Fig. 409). 

To my mind, this instrument is superior to all other axis-traction 
forceps, and with it excellent results can be obtained with a minimum 
expenditure of energy, and by its aid a delivery can occasionally be 
effected which would have been impossible with the ordinary instru¬ 
ments. One of its best points is the joint between the horizontal and 
vertical portions 
of the traction 
attachment, as a 
result of which 
the handle-bar 
can be held hori¬ 
zontally, even 
though the for¬ 
ceps is applied at 
the ends of the 
anteroposterior 

diameter of the pelvis. I use this instrument in all cases, without the 
traction-rods in low, and with them in mid and high forceps operations. 

Application of Forceps in Face Presentations .—In face presentations 
the application of forceps occasionally becomes necessary, but is usually 
successful only in the transverse and anterior varities, the blades being 


Fig. 405. —Morales’ Forceps. 


Fig. 406. 


Tarnier’s Original Axis-Traction Forceps. 














APPLICATIONS OF FORCEPS 


467 


applied to the sides of the head along the mento-occipital diameter, with 
the pelvic curvature directed toward the neck. Traction is made in a 
downward direction until the chin appears under the symphysis; then 
by an upward movement the face is slowly extracted through the vulva, 
the nose, eyes, blow, and occiput appearing in succession over the anterior 
margin of the perineum. 

Forceps should not he applied when the chin is directed tow r ard the 
hollow' of the sacrum, as delivery cannot be effected in that position. 
In exceptional cases, if version is out of the question, and conversion 
into a vertex presentation cannot be effected, an expert operator may 



Fig. 407. —Tarnier’s Forceps; Traction Rods in Place without Handle-BAB. 


endeavor to rotate the chin to a transverse and later to an anterior 
position before resorting to pubiotomy or craniotomy, though such at¬ 
tempts are rarely successful. 

Application of Forceps in Breech Presentations .—Occasionally the 
application of forceps is recommended in frank breech presentations, 
the blades being applied over the trochanters. This is very rarely in¬ 
dicated, as delivery can usually be effected more satisfactorily by the 
methods to be mentioned in the following chapter. 

From the time of Smellie, many authors have recommended the 

extraction of the 
after-coming head 
in breech presen¬ 
tations by means 
of the forceps. In 
such cases the 
body of the child 

is carried up over the abdomen of the mother, and the 
blades are introduced under it and applied to the sides 
of the head. As a matter of fact, it is never necessary 

to resort to the forceps under such conditions, so its 

employment is not to be recommended, since the more 
expert one becomes in the use of Mauriceau’s method of 
extraction the less frequently will difficulty be experienced in delivering 
the after-coming head. 

Prognosis.—Low and mild forceps operations, when intelligently per¬ 
formed upon healthy women under proper aseptic precautions, should 
not be followed by maternal mortality, the operation being undertaken 



Fig. 408.—Tarnier’s Forceps. 


to save maternal or foetal life. 

It is generally held that perineal tears occur more frequently in for¬ 
ceps than in spontaneous deliveries. This, however, should not be the 
case, provided that the head is extracted sufficiently slowly. Unfortu- 


FORCEPS 


408 

nately, it would appear as though the average operator, as soon as the 
head appears at the vulva, is seized with an almost uncontrollable desire 
to effect its immediate delivery by brusque traction, instead of imitating 
nature and devoting from fifteen to twenty minutes to overcoming the 
resistance of the perineum and vulval outlet. Leopold has stated that 
the forceps is the bloodiest of all obstetrical operations, and this is 
undoubtedly true if the child is rapidly dragged through a partially 
dilated birth canal by brute force. On the other hand, if properly 
employed, it is a means of sparing instead of destroying the perineum, 



Fig. 409. —Diagram showing Traction with Tarnier’s Forceps. 
A B in proper and X Y in improper manner (Ribemont-Dessaignes). 


inasmuch as the exit of the head can be controlled quite as effectively 
by means of the forceps as by any other procedure. 

Attempts at delivery through an imperfectly dilated cervix are most 
dangerous, and frequently give rise to deep cervical tears, which may 
lead to the death of the patient from hemorrhage or infection. More¬ 
over, the application of forceps requires an accurate diagnosis as to the 
position and presentation of the child, and when this is lacking, and 
the forceps is incorrectly applied in certain occipitoposterior and brow 
presentations, delivery can be effected only by brute force, which can 
hardly fail to cause serious lesions for mother and child. Similar un- 
toward results often follow an attempt to drag the head forcibly through 
a markedly contracted superior strait or pelvic outlet. 

The foetal mortality depends upon the position of the head and the 








LITERATURE 


469 


general difficulty of the operation. It should be practically zero in low 
and mid operations, except when a funnel-shaped pelvis has been over¬ 
looked. In a comparatively large experience, I can recall very few 
children whose deaths could be directly attributed to such operations 
when properly performed. On the other hand, the high forceps opera¬ 
tion is attended by a serious foetal mortality, which becomes still greater 
when the head is not engaged. In such cases the head may be subjected 
to injurious pressure, which may lead to the rupture of intracranial 
vessels and the subsequent death of the child. In rare instances actual 
fracture of the skull may occur, and occasionally the upper part of the 
occipital bone may become separated from its base. 

Occasionally the child may be born with facial paralysis, or the con¬ 
dition may develop shortly after birth. This is usually noted when the 
head has been seized obliquely, and is due to the pressure exerted by the 
posterior blade of the forceps upon the neighborhood of the stylomas¬ 
toid foramen, through which the nerve leaves the skull. Not every 
facial paralysis, however, following delivery by forceps, should be attrib¬ 
uted to the operation, as such a condition is occasionally encountered 
after a spontaneous labor, arid may be due to intracranial causes quite 
independent of the use of instruments. Full literature upon this subject 
up to 1901 will be found in Mace’s article. 


LITERATURE 

Aveling. The Chamberlens and the Midwifery Forceps. London, 1882. 

Baudelocque. De la maniere de se servir du forceps, etc. L ’art des accoclie- 
ments. Nouv. ed., Paris, 1789, t. ii, 300-343. 

Bill. Forceps Rotation of the Head in Persistent Occipito-posterior Positions. 
Am. Jour. Obst., 1918, lxviii, 791-795. 

Budin. L ’invention du forceps a double courbure. Prog-res medical, 1876, iv, 
779. 

Les Chamberlens. Lequel d’entre eux imagina le forceps. Obstetrique et Gyne- 
cologie, 1886, 659-668. 

Chapman. An Essay on the Improvement of Midwifery, etc. London, 1733. 

Chassagny. Le forceps, etc. Paris, 1871. 

Fonctions du forceps. Paris, 1891. 

Be Lee. The Treatment of Obstinate Occipito-posterior Positions. Jour. Am. 
Med. Assoc., 1920, lxxv, 145-147. 

The Prophylactic Forceps Operation. Am. J. Obst. and Gyn., 1920, i, 34-44. 

Farabeuf et Varnier. Introduction a 1’etude elinique et a la pratique des ac- 
couchements. Paris, 1891, 276-466. 

Fink. Zur Kritik der Kjellandzange. Zentralbl. f. Gyn., 1923, 668-684. 

Giffard. Cases in Midwifery. London, 1734. 

Hermann. Ueber eine neue Geburtszange. Berne, 1844. 

Hubert. Note sur l’equilibre du forceps et du levier. Memoires de 1 acad. royale 
de Belgique, 1860. 

Kielland. Ueber die Anlegung der Zange am niclit rotierten Kopf mit Besch- 
reibung eines neuen Zangemodelles, etc. Monatsschr. f. Geb. u. G}n., 191(5, 
xliii, 48-78. 


470 


FORCEPS 


Levret. Observations sur les causes et les accidents de plusieurs accouchements 
laborieux. Paris, 1747. 

Mace. Des paralysics faciales spontanes du nouveau-ne. L ’obstctrique, 1901, vi, 
517-526. 

Milne Murray. The Axis Traction Forceps, etc. Edinburgh Med. Jour., 1891, 
xxxvii, 142-158, 228-239. 

Morales. Modification nouvelle du forceps. Jour, de med. de Bruxelles, 1871, 
lii, 110-134. 

Mulder. Historia literaria et critica forcipum et vectium obstetriciorum. Lugd. 
Bat., 1794. 

Palfyn. See Levret. 

Poullet. Des diverses especes du forceps. Paris, 1883. 

Sanger. Die Chamberlens. Archiv f. Gyn., 1887, xxxi, 119-144. 

Saxtorph. Theoria de diverso partu, etc. Havniae et Lipsiae, 1772. 

Scanzoni. Lehrbuch der Geburtshiilfe, II. Aufl., 1853, 838-840. 

Smellie. A Treatise on the Theory and Practice of Midwifery. London, 1752. 

Tarnier. Description de deux nouveaux forceps. Paris, 1877. 

Williams. A Criticism of Certain Tendencies in American Obstetrics. New 
York State Jour. ofJVted., November, 1922. 

Witkowski. L’arsenal obstetrical. Paris, Steinheil. 


CHAPTER XXI 


EXTRACTION AND VERSION 

EXTRACTION 

Extraction in Breech Presentations.— The delivery of the child by 
traction when the feet protrude from the vulva in breech presentations 
was probably the earliest obstetrical operation. 

From the time of Hippocrates, up to the beginning of the sixteenth 
century, head presentations alone were considered normal, and hence 
all the authorities, with the exception of Celsus, advised the conversion 
of breech into vertex presentations at any cost, even though it rendered 
necessary amputation of the limbs. After the resuscitation of podalic 
version by # Ambroise Pare and Jacques Guillemeau, more rational views 
prevailed, so that in the seventeenth century we find Mauriceau advising 
the method of extraction which is in general use at the present time. 

As the technic of the operation varies according as one has to deal 
with a complete breech or a foot, or with a frank breech presentation, it 
will be necessary to consider the two conditions separately. In both 
the essential prerequisite for the successful performance of extraction 
lies in the complete dilatation of the cervix and the absence of any 
serious mechanical obstacle. It is true that in a certain number of cases 
extraction through an imperfectly dilated cervix is possible, but this is 
usually effected only at the cost of deep cervical tears. Moreover, the 
additional resistance offered to the passage of the head will generally 
lead to its extension, the arms at the same time becoming elevated over 
it, thereby so complicating and delaying delivery that the child is almost 
invariably lost. For these reasons, when prompt extraction is indicated 
in the interests of the mother, it should always be preceded by complete 
manual dilatation of the cervix. 

Indications for Extraction .—It has already been pointed out that 
the foetal mortality is considerably greater in breech than in vertex pres¬ 
entations, since in the former death from asphyxiation is almost inevi¬ 
table if the mouth of the child be not brought to the vulva within eight 
minutes after the appearance of the umbilicus. Complete delivery of 
the head is not essential, as all that is necessary, in case of delay, is to 
have the mouth in such a position as to permit the access of air with¬ 
out danger of aspiration of the vaginal contents. The untoward result 
may be due to one of several causes. Thus, the cord may be subjected 

471 


472 


EXTRACTION AND VERSION 


to such pressure between the pelvic brim and the head, as to check com¬ 
pletely the circulation. Less frequently the rapid decrease in the size 
of the uterus, following the extrusion of the body of the child, results 
in premature separation of the placenta before the head is born, so that 
death occurs unless extraction is promptly effected. 

Consequently, in all breech presentations, preparations should be 
made for extraction as soon as the feet or buttocks appear at the vulva, 
so that the operation can be promptly resorted to if, after the appear¬ 
ance of the umbilicus, the extrusion of the rest of the body does not 
rapidly follow. In a certain number of cases, no matter what the loca¬ 
tion of the breech, extraction may be called for by some condition 
which threatens the life of the mother or child, just as in vertex pres¬ 
entations. It should, however, be realized that the passage of meconium 
is without significance, as it is simply the result of the compression to 
which the abdomen of the child is being subjected. Moreover, it should 
be remembered that extraction by the feet constitutes the usual method 
of completing delivery following internal podalic version. Consequently, 
as that operation has a wide field of usefulness, extraction is employed 
in association with it more frequently than for primary breech pres¬ 
entations—in which event the joint procedure is designated as version 
and extraction. 

Extraction by the Feet .—Before beginning the operation, the patient 

should be placed upon a suitable 
operating table, but if one is not 
available she should be brought to 
the edge of the bed and subjected to 
the usual preliminary preparations. 
Complete anesthesia is desirable, 
even when the body of the child has 
already been born and only the head 
remains to be extracted. 

As a rule, extraction is a simple 
operation when the breech has been 
born spontaneously; whereas it is 
less so when the feet are still within 
the uterus. In the latter case, after 
“ironing out” the vaginal opening 
and pelvic floor, the entire hand 
should be introduced into the vagina 
and both feet seized, the ankles be¬ 
ing grasped in such a manner that 
the second finger lies between them. The feet are then brought down 
into the vagina, and traction is made until they appear at the vulva. 
If, however, difficulty is experienced in seizing both feet, one should be 
brought down, and the hand immediately reintroduced in order to grasp 
and extract the other. 

As soon as the feet have been drawn through the vulva, they should 
be wrapped in a sterile towel so that a firmer grasp may be obtained, 






EXTRACTION 


475 


although moie difficulty can usually be accomplished by tlie maneuvers 
. ust described. In doing this, particular care must be taken to carry the 
lingers up to the elbow and to use them as a splint, for, if they are 
merely hooked over the arm, the humerus or clavicle is exposed to great 
danger of fracture. 

Very exceptionally the arm is found around the back of the neck, 
when its delivery becomes still more difficult. If it cannot be freed in 
*he manner just described, its extraction may be facilitated by rotating 
i he child through half a circle in such a direction that the friction 
exerted by the birth canal will serve to draw it toward the face; but 
if this fails, it must be forcibly extracted by hooking a finger over it. 
'n this event, fracture of the humerus or clavicle is, unfortunately, very 



Fig. 413. —Breech Extraction; Scapulae Visible. 


common, and its probability should be pointed out to some responsible 
member of the family. Such an accident, however, is not very serious, 
as good union can always be secured by appropriate treatment. 

After the shoulders have been born, the head usually occupies an 
oblique diameter of the pelvis with the chin directed posteriorly, when its 
extraction is best effected by Mauriceaus maneuver (Figs. 416 and 
417). For this purpose, the index finger of one hand is introduced 
into the mouth of the child and applied over the superior maxilla, while 
the body rests upon the palm of the hand and the forearm, with the 
legs straddling the latter. Two fingers of the "other hand are then 
hooked over the neck, and, grasping the shoulders, make downward 
traction until the occiput appears under the symphysis. The body of 
the child is now raised up toward the mother’s abdomen, and the mouth, 




476 


EXTRACTION AND VERSION 


nose, brow, and eventually the occiput successively emerge over the 
perineum. Traction should be exerted only by the fingers over the 
shoulders, and not by the finger in the mouth; since the latter may slip 
from the superior maxilla and come to rest upon the inferior maxilla 
and base of the tongue, as a consequence of which serious injury may 
be done to the child if energetic traction be employed. 

This maneuver was first practiced by Mauriceau in the seventeenth 



Fig. 414.—Breech Extraction; (A) Upward traction to Effect Delivery of 
Posterior Shoulders. (B) Freeing Posterior Arm. 

century, but for some reason fell into disfavor. Nearly a hundred years 
later Smellie described a similar procedure, but rarely made use of it, 
as he preferred the employment of forceps. In the meantime other 
devices came into use, until G. Veit, in 1863, directed attention to the 
inestimable advantages which Mauriceau’s method of extraction pos¬ 
sessed over all others. For this reason in Germany the procedure is fre¬ 
quently called after Veit, or, when greater accuracy is desired, is desig- 





EXTRACTION 


477 



nated as the Mauriceau-Smellie-Veit maneuver. Litzmann, however, 
correctly pointed out the impropriety of such a nomenclature, and 
insisted that only the name of the original inventor—Mauriceau—should 
be used in describing it. Numerous other methods of extraction have 
been devised, Winckel being able in 1888 to collect 21 different procedures 
from the literature, although none 


as 


that 


has proved as serviceable 
of. Mauriceau. 

In the vast majority of cases 
the back of the child eventually 
rotates toward the front, no mat¬ 
ter what its original position; but 
when it does not take place spon¬ 
taneously the movement may be 
inaugurated by making stronger 
traction upon the leg, which 
would naturally rotate anteriorly. 

If this does not bring about the 
desired result, and the back re¬ 
mains posterior after the birth of 
the shoulders, extraction must be 
begun with the occiput posterior. 

As a rule, rotation can still be 
effected by means of the finger 
in the mouth, after which the 
head can be extracted by 
Mauriceau’s maneuver. When, 
however, this is not possible, de¬ 
livery must lie attempted, with 
the head in its abnormal position, 
by the employment of a modified 
Prague maneuver, which is so 
called for the reason that its ad¬ 
vantages were strongly urged and 
practiced more particularly by 
Kiwisch of that city, although it 
had been described by Pugh a cen¬ 
tury earlier. The procedure is 
somewhat as follows: Two 

fingers of one hand grasp the shoulders from below, while the other 
hand draws the feet up over the abdomen of the mother. As a result 
the occiput is born first and the perineum is necessarily subjected to 
greater liability of rupture. 

Extraction of Frank Breech Presentations.—When indications for de¬ 
livery arise after the frank breech has descended deeply into the birth 
canal its extraction can usually be effected without difficulty by hooking 
the index finger of one hand into the anterior groin and making traction 
until the buttocks appear, at the vulva, the index finger of the other 


r 






Fig. 415. —Breech Extraction; Delivery 
of Anterior Shoulder by Downward 
Traction. 







Fig. 416 . —Breech Extraction; Mauriceau’s Maneuver, Downward Traction. 



Fig. 417. —Breech Extraction; Mauriceau’s Maneuver, Upward Traction 














Fig. 418. —Delivery of After-Coming Head, Reversed Prague Maneuver. 



Fig. 419. —Extraction of Frank Breech; Finger in Anterior Groin. 












480 


EXTRACTION AND VERSION 


hand being then inserted into the posterior groin in order to furnish 
additional aid. 

On the other hand, when the breech is high up, delivery is much 
more difficult. In such cases it is advisable to try to decompose the 
wedge and to bring down one or both feet, which can be readily accom¬ 
plished if the membranes have only recently ruptured, but becomes 
extremely difficult if a considerable time has elapsed after the escape 
of the liquor amnii, more particularly if the uterus has become tightly 
contracted over the child. 

In many cases the employment of the following maneuver suggested 



by Pinard will aid materially in bringing down the foot: Two fingers 
are carried up along one leg to the knee and push it away from the 
middle line. This is usually followed by spontaneous flexion, and the 
foot of the child will be felt to impinge upon the back of the hand, 
when it can be readily seized and brought down (Fig. 421). 

In view of the fact that it is often very difficult to seize and bring 
down a foot late in the second stage of labor, Ahlfeld and others have 
suggested the propriety of rupturing the membranes as soon as the 
cervix is fully dilated, and bringing down a foot prophvlacticallv, so 
that a convenient tractor may be available in case extraction becomes 
necessary. This can be readily accomplished, but is not advisable as a * 








EXTRACTION 


481 



routine practice, since the frank breech forms a much better dilating 
wedge than the incomplete breech presentation. The procedure is jus¬ 
tifiable, however, when it appears probable that extraction may eventually 

be required, as in elderly primiparae, or in patients suffering from heart 
lesions. 

If the indication for delivery is urgent, and it is impossible to bring 
down a foot, the child 
must he extracted as it 
lies. For this purpose 
the index finger of one 
hand is hooked into 
the anterior groin, and 
strong downward trac¬ 
tion made, supple¬ 
mented, if necessary, 
by the use of the other 
hand, wdiich grasps the 
wrist. This procedure 
is continued until the 
posterior buttock has 

reached the pelvic 

floor, wffien the index 
finger of the other 
hand is hooked into 

the posterior groin and 
traction then made 

wdth both hands. As 
soon as this becomes 
possible, delivery can 

usually be readily 

effected, but, unfor- Fig. 421. —Pinard’s Manuever for Bringing Down a 

tunately, in a consid- Foot IN Frank Breech Presentation. 

erable number of cases, 

it is extremely difficult to bring the breech low enough to secure this 
advantage. For this reason, when the frank breech is high up, its ex¬ 
traction should not he attempted unless imperatively demanded by the 
condition of the mother or child. 

As soon as the buttocks are born, first one leg and then the other is 
drawru out and extraction is accomplished as described above. As was 
said before, traction should be supplemented by pressure upon the abdo¬ 
men from above. This precautionary measure should never be neglected, 
as delivery can frequently he accomplished by its aid when it would 
be impossible if traction by the fingers w r ere alone relied upon. Indeed, 
it is not until one has attempted a difficult frank breech extraction 
that one learns how r little force can he exerted by the fingers. 

Use of Forceps .—In view of the difficulty which sometimes attends 
the extraction of the frank breech wffien high up, Lusk, Budin, Reynolds, 
and other authorities have recommended the employment of forceps, 
the blades being applied obliquely, one over the sacrum and the other 





482 


EXTRACTION AND VERSION 


over the thighs. Up to the present time I have had no experience with 
this procedure, having been able to effect delivery in all my cases by 
traction exerted with a finger in the groin. When this fails, the appli¬ 
cation of forceps is justifiable, although when the breech is high up it 
should not be attempted except under pressing indications. 

In all forms of breech presentation, the application of forceps to the 
after-coming head has been advocated. It was first practiced by Smellie, 
but is rarely utilized by obstetricians who have made themselves familiar 
with Mauriceau’s maneuver. When forceps are used, the body of the 
child is elevated toward the abdomen of the mother and the blades 
applied under it to the sides of the head. 

The Fillet .—In frank breech extractions, it is sometimes convenient 

to make use of the fillet. This mav consist of several thicknesses of 

%/ • 

sterile ganze bandage which are passed over the anterior groin. The 
fillet is a very efficient tractor, but its application offers considerable 
difficulty. Unless the operator has at his disposal a specially constructed 
instrument, a fairly satisfactory carrier may be improvised from a rubber 
catheter, through which a piece of stout thread is passed, a loop being 
allowed to protrude from the eye. A stylet is then introduced and, an 
appropriate curve having been given to the catheter, the bent extremity 
is passed around the anterior groin until the fingers in the vagina can 
seize the loop, to which one end of the fillet is attached and then 
cautiously drawn up into place. 

Aside from the difficulty encountered in applying it, the disadvantage 
of the fillet is its liability to cut through the skin of the groin; but 
this can be avoided by employing several thicknesses of gauze and taking 
care that they do not become twisted into a cord. 

The older authors advocated making traction upon the groin by 
means of a metallic hook. This instrument should never be employed 
upon living children on account of its liability to cause fracture of the 
femur. On the other hand, when the child is dead, and such an accident 
is a matter of indifference, the hook affords a convenient means of 
making traction. 

In all forms of breech extraction the prognosis for the mother is 
good, although it is more serious in frank breech than in the other 
varieties. In the former the increased manipulation affords greater 
opportunity for infection; while the attempt to reach the posterior groin 
often gives rise to deep, and sometimes to complete, tears before the 
buttocks have reached the perineum. In extraction by the feet, on the 
other hand, provided the outlet has been “ironed out” as a preliminary 
procedure, the liability to perineal tears is no greater, and is possibly 
less, than in head presentations. Moderate degrees of disproportion be¬ 
tween the size of the head and the pelvis scarcely influence the maternal 
prognosis, since the pressure of the head upon the soft parts lasts but a 
few seconds, instead of being prolonged for hours as in head presenta¬ 
tions. 

For the child, however, the outlook is not so favorable, and becomes 
more serious the higher the presenting part is situated at the beginning 
of the operation. In addition to the increased liability to tentorial tears 


CEPHALIC VERSION 


483 


and intracerebral hemorrhage, which Eardley Holland, Capon, and 
Crothers have shown are inherent to breech presentations, the foetal 
mortality is augmented by the greater probability of the occurrence of 
traumatism during extraction. 

As has already been said, fractures of the humerus and clavicle cannot 
always be avoided when freeing the arms, while fracture of the femur 
may occur in difficult frank breech extractions. Occasionally, hematomata 
of the sternocleidomastoid muscles develop after the operation, though 
they usually disappear spontaneously. More serious results, however, 
may follow separation of the epiphyses of the scapula, humerus or femur. 
Exceptionally, paralysis of the arm follows pressure upon the brachial 
plexus by the fingers in making traction, but more frequently it is due 
to over-stretching the neck while freeing the arms. When the child is 
forcibly extracted through a contracted pelvis, spoon-shaped depressions 
or actual fractures of the skull may result, which generally prove fatal, 
while occasionally even the neck may be broken when great force is 
employed. In general it may be said that in simple extractions the 
prognosis for the child is excellent, while in complicated ones it is 
dubious. 


VERSION 

Version, or turning, is an operation through which the presentation 
of the foetus is artificially altered, one pole being substituted for the 
other, or an oblique or transverse being converted into a longitudinal 
presentation. 

According as the head or breech is made the presenting part, the 
operation is spoken of as cephalic or podalic version, respectively. It 
is also designated according to the method by which it is accomplished. 
Thus we speak of external version when the manipulations are made 
exclusively through the external abdominal wall; of internal version 
when the entire hand is introduced into the uterine cavity; and of 
combined version when one hand manipulates through the abdominal 
wall, while two or more fingers of the other are introduced through the 
cervix. 

Cephalic Version.—This operation was practiced from the most re¬ 
mote antiquity, and only gradually fell into disfavor after the introduc¬ 
tion of podalic version by Pare and his followers. After the discovery 
of Wigand (1807) that the position of the child could easily be altered 
by manipulations through the abdominal walls, external cephalic version 
came into more general use, and since the publications of Hubert and 
Pinard has become a well-recognized procedure in certain conditions. 

The object of the operation is to substitute a vertex for a less favor¬ 
able presentation. As it does not, however, afford a means for imme¬ 
diate delivery, its field of usefulness is comparatively limited, and its 
employment is stdl further restricted by vaiious contia-indications. 

Indications .—If a breech or transverse presentation is diagnosed in 
the last weeks of pregnancy, its conversion into a vertex should be 
attempted by external maneuvers, provided there be no marked dispro- 









484 


EXTRACTION AND VERSION 


portion between the size of the child and the pelvis. Cephalic version is 
indicated by reason of the increased foetal mortality attending spon¬ 
taneous delivery in breech presentations; while if the child lies trans¬ 
versely a change of presentation is imperatively demanded, inasmuch 
as a natural labor is out of the question, and if appropriate measures 
are not adopted the lives of both mother and child will be lost. 

Unfortunately, after the accomplishment of external cephalic version, 
the child tends to return to its original position, unless the head at once 
becomes engaged. Consequently many authorities recommend that the 
child be held in place by a suitable abdominal bandage in the hope that 
it will favor engagement, but in my experience such attempts are useless. 
Moreover, the operation can be accomplished only under the following 
conditions: (1) The presenting part must not be deeply engaged; 

(2) the abdominal wall must be sufficiently thin to admit of accurate 
palpation; (3) the abdominal and uterine walls must not be too irritable; 
(4) the uterus must contain a sufficient quantity of liquor amnii to 
permit the easy movement of the child. Given these essentials, external 
cephalic version should always be attempted, since it is absolutely harm¬ 
less, and, if the new position is maintained, may do away with the 
necessity for serious operative procedures at the time of labor. 

In the early stages of labor, before the membranes have ruptured, the 

same indications hold 
good, and at this time 
may be extended to 
oblique presentations 
as well, though these 
usually right them¬ 
selves spontaneously 
as labor progresses. 
On the other hand, 
external cephalic ver¬ 
sion can be effected 
but rarely after the 
cervix has become 
fully dilated and the 
membranes have rup¬ 
tured. Serious pelvic 
contraction is a de¬ 
cided contra - indica¬ 
tion, since, although 
external version may 
be readily accom¬ 
plished, the procedure 
is useless, as more radical operative measures will be necessary before 
delivery can be effected. 

Methods .—Cephalic version may be brought about either by external 
manipulations alone, or by the combined method—with one hand on the 1 
abdomen and two or more fingers, or even the whole hand, in the uterus. 
During pregnancy the former is the only method applicable, and at the 





Fig. 422. —External Cephalic Version (Pinard). 
















PODALIC VERSION 


485 


time of labor it should be employed whenever feasible. The technic has 
been carefully described by Pinard, and is somewhat as follows: The 
patient’s abdomen having been bared, the presentation and position of 
the child are carefully mapped out. The foetal poles are then seized 
with either hand, and the one which we wish to present is gently stroked 
toward the superior strait, while the other is moved in the opposite 
direction. After version has been completed, the child will tend to 
return to its original position unless engagement occurs; but at the 
time of labor the head may be pressed down into the superior strait and 
held firmly in position until it becomes fixed under the influence of the 
uterine contractions. 

At the time of labor, if external manipulations prove futile, cephalic 
version may be accomplished by the combined or bipolar method of 
Braxton Hicks as soon as the cervix is sufficiently dilated to admit of 
two fingers. It, however, is rarely employed, as in such circumstances, 
it is usually advisable to wait until the cervix is fully dilated, and then 
to rupture the membranes and do a podalic version followed by ex¬ 
traction. For carrying out the former procedure Hicks gave the follow¬ 
ing directions: 

“Introduce the left hand into the vagina as in podalic version. Place 
the right hand on the outside of the abdomen in order to make out the 
position of the foetus and the direction of the head and feet. Should 
the shoulder, for instance, present, then push it with one or two fingers 
on the top in the direction of the feet. At the same time pressure by 
the other hand should be exerted upon the cephalic end of the child 
This will bring the child close to the os. Then let the head be received 
upon the tips of the inside fingers. The head will then play like a ball 
between the hands, and can be placed at almost any part at will. . . . 
It is well, if the breech will not rise to the fundus readily and the head 
is fairly in the os, to withdraw the hand from the vagina and with it 
press up the breech from the exterior” (Fig. 426). While the credit 
for popularizing this procedure undoubtedly belongs to Hicks, it is in¬ 
teresting to note that it had been described by Marmaduke Wright, of 
Cincinnati, in 1854 ; ten years before the appearance of Hicks’s first 
publication, but had remained buried in an obscure publication. 

Busch, D’Outrepont, and others advocated attempting cephalic ver¬ 
sion after complete dilatation of the cervix, by introducing one hand 
into the uterus and seizing the head, while the other is employed for 
external manipulations. This, however, is no longer done, as in such 
circumstances it is preferable to perform internal version, which is no 
more dangerous, and at same time permits immediate delivery if 
necessary. 

Podalic Version.—By this is understood the turning of the child by 
seizing one or both feet, and drawing them through the cervix, the 
operation being usually followed by extraction. Podalic version was 
introduced and warmly advocated by Pare, and, until the invention of 
the forceps, afforded the only means of artificially delivering unmuti¬ 
lated children. It is interesting to note that Guillemeau, one of Pare’s 
students, was enabled b.v this means to save his master’s daughter from 


EXTRACTION AND VERSION 


4S6 


dying of hemorrhage due to placenta previa. The value of the operation 
was recognized and insisted upon by Louise Bourgeois, Mauriceau, and 
among many others by De la Motte, who employed it very frequently 
with most excellent results. 

Indications .—Podalic version is indicated in two great groups of cases 
—namely, in transverse or oblique presentations, and in head presenta¬ 
tions in which it is believed that delivery can be more safely and more 
rapidly accomplished after version. 

The necessity for version in transverse and oblique presentations is 
obvious. In abnormal head presentations, when the face, brow, or occiput 



Fig. 423. —Patient in Position for Internal Podalic Version. Inset Shows Hand 

in Uterus Grasping the Feet. 


is posterior and movable above the superior strait, delivery can frequently 
be more readily accomplished after version than by any other means. 
Podalic version is usually the operation of choice in prolapse of the ex¬ 
tremities or umbilical cord, and in many cases of placenta previa. More¬ 
en er, when the child presents some deformity, delivery is sometimes 
very much facilitated after version. Generally speaking, the operation 
is indicated in all cases requiring prompt delivery when the head is 
floating at the superior strait or is but slightly engaged, provided there 
is no great disproportion between its size and that of the pelvis. In 
such circumstances it is usually a safer and more satisfactory procedure 
than the application of high forceps. 









PODALIC VERSION 


487 


One of its widest fields of usefulness is in accouchement force, after 
the cervix has been completely dilated by means of the hand or of the 
balloon, especially in preeclamptic toxemia and antepartum hemorrhage. 
In such circumstances, the presenting part having been displaced dur¬ 
ing the manipulations employed for dilating the cervix, version and 
extraction constitute the readiest and most conservative method of de¬ 
livery. 

The most favorable time for performing the operation is just after 
the cervix has become fully dilated, but before the membranes have 
ruptured. In this event, the amniotic fluid will be still in utero and 
the child readily movable in any direction. On the other hand, podalic 
version should never be attempted when the child is suffering from 
hydrocephalus, nor when the cervix is imperfectly dilated, except in 
certain cases of placenta previa, when the bipolar method of Braxton 
Hicks is employed. It sometimes happens that the patient is not seen 
until long after rupture of the membranes, and conditions may then be 
present which render the operation extremely difficult or even impossible. 
For example, the uterus may be tetanicallv contracted and so tightly 
applied to the body of the child as to render even the introduction of 
the hand extremely difficult. In other cases, the contraction ring may 
have risen to such an extent and the lower uterine segment be so 
stretched as to render the operation dangerous in the highest degree, as 
the attempt at version will probably lead to rupture of the uterus. 

Before Cesarean section had become a reasonably safe procedure, 
many authorities practiced so-called “prophylactic version” in the treat¬ 
ment of moderate degrees of pelvic dystocia. In this the membranes 
were ruptured as soon as the cervix was fully dilated and the child 
turned and extracted, with the idea that the head would withstand 
momentary compression better than continued pressure against the pelvic 
brim in a long second stage. The operation is no longer employed for 
two reasons: first, on account of its relatively poor results, and second, 
because it converted all cases into operative labors, and deprived nature 
of the chance of demonstrating what she could accomplish. 

Within recent years Potter of Buffalo has advanced the revolutionary 
doctrine that all labors not complicated by serious disproportion, should 
be ended by version and extraction, in the belief that by so doing the 
duration of labor is shortened, the patient is spared unnecessary suffer¬ 
ing, and the danger to the child is not increased. In his monograph 
which appeared in 1922, he stated that, he had performed over four 
thousand versions, and during the two years ending August 31st, 1921, 
had delivered 2,253 patients in private practice, as follows: 1,858 by 
version, 180 by cesarean section, 64 by forceps, 31 spontaneously and 130 
various. In other words, all but 31 patients were delivered by operative 
means, and these escaped only because their labors had ended spon¬ 
taneously before his arrival. 

As far as can be gathered from his writings, as soon as the cervix 
is partially dilated and offers but little resistance, Potter completes its 
dilatation manually, and without removing the hand from the uterus, 
ruptures the membranes and turns and extracts the child. 




488 


EXTRACTION AND VERSION 


If his claims are substantiated, he will have effectively revo¬ 
lutionized obstetrics and will have converted child-birth from a 
physiological and in great part spontaneous process into a routinely 
operative one. Furthermore, he will have done away with the necessity 
for any knowledge of the mechanism of labor and in great part with 
everything formerly taught concerning the practice of obstetrics. He 
may be right, but I doubt it. Of two things, however, I am sure: first, 
that he is an extraordinarily accomplished operator, and second that 
should his practice become generally adopted the mortality from child¬ 
birth will increase, and many more children will perish than at present. 

Unfortunately, in his monograph, he is more concerned with the 
technic of the operative procedure than with the ultimate results to his 
patients. He does, however, state that during the year 1920, 41 chil¬ 
dren were stillborn and 34 others died during the two weeks following 
delivery; a mortality of 6.73 per cent., which does not commend his 
practice, as in the first ten thousand deliveries in our service the foetal 
mortality was practically the same—namely 7 per cent. When, however, 
it is remembered that Potter’s clientele is composed of private patients, 
in whom syphilis and contracted pelvis occur comparatively rarely, while 
ours consists of public ward patients, more than one-half of whom are 
black and many of whom are admitted after hours or days of neglect and 
sometimes in a moribund condition, the contrast is not flattering. 
Furthermore, when it is recalled that the majority of our patients were 
delivered by a succession of young men learning the rudiments of their 
art, while Potter's patients were delivered by probably the most dexterous 
obstetrical operator in the world, only one of two conclusions can 
be drawn: either that dexterity and training count for nothing, which 
is contrary to all experience, or that some inherent defect in Potter’s i 
practice counterbalances such advantages. 

I am convinced that the latter is the case, as I know from my own ! 
experience that in routine version and extraction technical difficulties 
will occasionally be encountered, which will inevitably increase the foetal 
mortality. For these reasons I advise against any wide acceptance of • 
Potter’s teaching; but at the same time, it must be admitted that it j 
has rendered an important service by forcibly bringing to the attention 
of the American profession the merits of a valuable procedure, which 
was in a fair way of being forgotten; as well as to make several impor- 1 
tant contributions to its technic. 

Technic .—For the performance of internal podalic version the patient ! 
should be placed upon a suitable table and the usual preoperative prepara¬ 
tions made. She should not be placed in the usual obstetrical posture, 
but instead the legs should be spread widely apart and held by assistants 
at about the same level as the body (Fig. 423). Version should never 
be attempted without an accurate diagnosis as to the presentation and 
position of the child, nor as to the existence of disproportion between 
its size and that of the pelvis. Its performance will be greatly facilitated, 
by the use of long rubber gloves reaching to the elbow, as recommended 
by Potter, and by an extensive preliminary “ironing out” of the vaginal 
outlet and pelvic floor. Version is easiest effected while the membranes 



PODALIC VERSION 


489 



are intact, and becomes increasingly difficult with every half-hom after 
their rupture. 

The operative technic varies somewhat, according as one has to do 
with a head or a transverse position. In the first instance the hand 
and arm must be introduced considerably further into the birth canal 
than in the latter, which is facilitated by free lubrication of the operat¬ 
ing hand and arm by albolene or green soap. It is usually taught that 
the choice of the hand to be employed depends upon the location of the 
small parts, and that if the back be directed to the left, the feet can be 
most convenientlv seized with the left hand, arid vice versa. Potter, 
however, has taught us, and I agree with him, that the left hand can 
be used equally satisfactorily no matter what the position of the feet 
may be. 

Accordingly, if the membranes are still intact, the left hand is passed 
through the cervix and carried up into the uterine cavity until it reaches 
the neighborhood of the feet. The membranes are then ruptured, and 
if possible both feet are seized as shown in the inset io Fig. 423, and 
downward traction is made. Ordinarily the child turns without diffi¬ 
culty, so that the feet are readily brought down 
into the vagina, and thence through the out- 


Fig. 424, a. —Version; Transverse Pres- Fig. 424, b . —Version; Transverse Pres¬ 
entation, Back Anterior, Seizure of entation, Back Anterior, Seizure of 
Lower Foot. Upper Ioot. 


let. When the knees emerge, one knows that version has been effected, 
after which delivery is completed by extraction as already described. 
r pp 0 seizure of both feet materially facilitates the opeiation, so that 
























* 490 


EXTRACTION AND VERSION 



if at first only one can be seized it should be brought through the cervix, 
and the hand immediately reintroduced into the uterus in order to 
grasp and bring down the other. Indeed, it should be the rule not to 
attempt to complete the version until both feet are available. 

If the membranes have already ruptured and the head is engaged, 
version is always more difficult. In this case, after pushing the head 
out of the pelvic hrim, the hand should he introduced past it, when the 
feet are seized and brought down as before. Of course, if the amniotic 
fluid has long since drained off, and the uterus is tightly applied over 


Fig. 425, a . —Version; Transverse Pres- Fig. 425, b . —Version; Transverse Pres¬ 
entation, Back Posterior, Seizure of entation, Back Posterior, Seizure of 
Upper Foot. Lower Foot, showing Arrest of 

Buttocks at the Pelvic Brim. 

the child, this may be difficult or impossible, and if persisted in after 
the lower uterine segment has become markedly stretched may result 
in rupture of the uterus. 

In transverse presentations, it is likewise desirable to bring down 
both feet, but, in case this cannot readily be accomplished, one foot will 
suffice. In this event, however, the choice of the foot is a matter of 
very considerable importance. When the back is directed anteriorly, 
the lower one should be seized, as by so doing the back of the child is 
kept directed toward the symphysis; whereas, if the upper foot be 
seized, the back may turn in the opposite direction. On the other hand, 
when the back looks posteriorly, the upper is the foot of choice, since 
traction upon it will cause the back to rotate to the front; while, if 

























PODALIC VERSION 


491 



the lower foot be seized, although anterior rotation will usually occur, 
the upper buttock is liable to impinge upon the anterior portion of 
the pelvic brim, and great force may become necessary to effect its 
dislodgment (Figs. 424 and 425). 

Not a few cases of transverse presentation are complicated by the 
prolapse of an arm into the vagina. In such circumstances, a fillet should 
be applied around the wrist and held loosely by an assistant, while 
version is performed in the usual manner. In this way the arm is 
prevented from becoming extended over the head, and the necessity of 
freeing it during extraction is obviated. 

Whatever may have been the original position of tin child, firm pres¬ 
sure should be exerted upon the 
fundus of the uterus as soon as 
extraction is begun, in order to 
prevent extension of the head or 
arms, and at the same time to 
facilitate delivery. 

Combined Podalic Version. 

—In other instances, particu¬ 
larly in placenta previa, version 
may be attempted by the com¬ 
bined or bipolar method of 
Hicks, as soon as the cervix is 
sufficiently dilated to admit two 
fingers. With these the present¬ 
ing part is dislodged and pushed 
upward, while the external hand 
gradually brings the breech 
downward toward the external 
os. As soon as a foot can be 
felt it is seized by the two 
fingers and drawn through the 
cervix. For the time being this 
finishes the operation, as extrac¬ 
tion should not be thought of 
until the cervix is fully dilated, 
for it can be effected only at the 
cost of deep cervical tears (Fig. 

426). 

Prognosis .—For the mother 
the prognosis following podalic 
version is excellent in properly selected cases, provided the patient be in 
good condition at the commencement of the operation. On the other 
hand, when attempted in the case of a tetanically contracted uterus, 
or when the lower uterine segment is overstretched, forcible attempts at 
version may lead to the rupture of the organ and death. 

The prognosis for the child is fairly good, and depends upon the 
nature of the indication and the difficulty experienced in extraction. On 
the other end, if the operation be undertaken through an imperfectly 


Fig. 426. —Bipolar Podalic Version 
(B umm). 










492 


EXTRACTION AND VERSION 


dilated cervix, and the child's head be arrested by the external os, the 
time required for its extraction is usually so great that death from 
asphyxiation is inevitable. Moreover, in cases of marked pelvic contrac¬ 
tion, the foetal mortality is very high. In many such cases forcible 
traction may enable one to deliver the child, but usually not until after 
the cord has been so long compressed as to have caused pronounced 
asphyxia and death, not to mention injuries to the head resulting from 
pressure. 

LITERATURE 


Ahlfeld. Ueber Behandlung gedoppelten Steisslagen, etc. Archiv f. Gyn., 1873, 
v, 174-176. 

Bourgeois, Louise. Observations diverses, etc. Paris, 1609. 

Budin. Tarnier et Budin, Traite de Part des accouchements. 1901, t. iv, 296. 

Capon. Intracranial traumata in the New-born. Jour. Obst. and Gyn. Br. Emp., 
1922, xxix, 572-590. 

Crothers,- Injury to the Spinal Cord in Breech Extraction as an Important 
Case of Foetal Deaths, etc. Am. Jour. Med. Sci., 1923, clxv, 94. 

De la Motte. Traite complet des accouchements. Nouv. ed., Leiden, 1729. 

D’Outrepont. Abh. und Beitrage, Wurzburg, 1817, Theil I, 69. 

Guillemeau. De l’heureux accouchement des femmes. Paris, 1609. 

Hicks. On Combined External and Internal Version. London, 1864. 

Holland. Cranial Stress in the Foetus During Labor. Jour. Obst. and Gyn. 
Br. Emp., 1922, xxix, 551-571. 

Hubert. Quelques faits sur les presentations vicieuses du foetus et sur la possi¬ 
bility de les corriger par les manipulations exterieures. Annales de gyn. et de 
paed., 1843, aout. 

Kiwisch. Beitrage zur Geburtskunde. Wurzburg, 1846, I. Abth., 69. 

Litzmann. Der Mauriceau-Levret ’sene Handgriff. Archiv f. Gyn., 1887, xxxi, 
102-118. 

Lusk. The Science and Art of Midwifery. New York, 1895, 338-391. 

Mauriceau. Le moyen d’accoucher la femme, quand 1 ’enfant presente un ou 
deux pieds les premiers. Traite des maladies des femmes grosses, 6me ed., 
1721, 280-285. 

Par:£. Edition Malgaigne, 1840, t. ii, 623. 

Pinard. De la version par les manoeuvres externes. Traite du palper abdominal, 
Paris, 1889. 

Quoted by Farabeuf and Varnier, Introduction a U etude clinique des accouche¬ 
ments. Paris, 1891, 185-187. 

Potter. The Place of Version in Obstetrics. St. Louis, 1922. 

Pugh. A Treatise on Midwifery chiefly with Regard to Operation. London, 1754. 

Reynolds. The Value of Forceps in Complicated High Arrest of the Breech. 
Amer. Jour. Obst., 1892, xxvi, 586. 

Smellie. The First Class of Preternatural Labors, when the Feet, Breech, or 
Lower Parts of the Foetus Present. A Treatise on the Theory and Practice of 
Midwifery, eighth edition, 1774, 195-206. 

Veit, G. Ueber die beste Methode zur Extraction des nachfolgenden Kindes- 
kopfes. G.reifswalder med. Beitrage, 1863, ii, Heft I. 

Wigand. Ueber Wendung durch aussere Handgriffe. Hamburger med. Mag., 
1807, i, 52. 

Winckel. Zur Beforderung der Geburt des nachfolgenden Kopfes. Verh. d. 
deutschen Gesellsch. f. Gyn., 1888, ii, 19-32. 

Wright. Difficult Labors and Their Treatment. Trans. Ohio State Med. Soc., 



1854, 59-88. 



CHAPTER XXII 


CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


CESAREAN SECTION 

In this operation the child is removed from the uterus through an 
incision in the abdominal and uterine walls. The origin of the term 
has given rise to a great deal of discussion. It has been generally 
asserted that Julius Caesar was brought into the world by this means 
and obtained his name from the manner in which he was delivered (a 
caeso matris utero). This explanation, however, can hardly be cor¬ 
rect, as his mother, Julia, lived many years after her son’s birth; and, 
besides, Julius was not the first of his name, since there is mention of 
a priest named Caesar who lived several generations before. The fol¬ 
lowing view, however, would appear to be more plausible. In the Roman 
law, as codified by Numa Pompilius, it was ordered that the operation 
should be performed upon women dying in the last few weeks of preg¬ 
nancy. This lex regia, as it was called at first, under the emperors 
became converted into the lex caesarea, and the procedure itself became 
known as the cesarean operation. 

History. —The history of cesarean section may be said to extend over 
four periods, the first lasting from the earliest times to the beginning 
of the sixteenth century. During this period the operation was occa¬ 
sionally resorted to after the death of the mother, in the hope of saving 
the child, but it is improbable that it was practiced upon the living 
woman, although several authorities are inclined to believe that certain 
passages in the Talmud may be so interpreted. The fact that Dr. Felkin 
saw a cesarean section performed by the natives in Uganda renders it 
possible that it may have been employed upon the living woman at an 
early period by certain of the uncivilized races. 

The second period extends from the year 1500 to 1876, when Porro 
described his method of amputating the pregnant uterus. 

According to Casper Bauhin, the first cesarean section upon a living 
woman was performed in 1500, when Jacob Nufer, a castrator of pigs at 
Sigerhausen, Switzerland, operated successfully upon his own wife after 
she had been given up by the midwives and barbers in attendance. The 
fact, however, that the woman had five spontaneous labors later would go 
to show that this was not a true cesarean section, but probably the 
removal of an extra-uterine child from the abdominal cavity. 

Frangois Rousset, a contemporary of Pare, wrote a treatise upon the 
subject in 1581, in which he gave the histories of a number of cesarean 
sections collected from various sources. Several of them were apocryphal, 

493 


494 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


while others, in all probability, were operations for advanced extra- 
uterine pregnancy. His article, however, had the merit of directing 
attention to the operation and to the possibility of performing it upon 
the living woman. The first authentic cesarean section was probably 
done in 1610 by Trautmann, of Wittenberg. Following this, it was 
occasionally performed until it became temporarily eclipsed by sym¬ 
physeotomy in 1777, to be taken up again after the latter operation had 
fallen into disrepute. 

During this period, the uterus was simply incised and the child ex¬ 
tracted. The uterine walls were not sutured, the contraction and re¬ 
traction of the organ being relied upon to check hemorrhage. Most of 
the women perished from hemorrhage or infection. Sutures were first 
employed by Lebas (1769), but did not come into general use until after 
the appearance of Sanger’s epoch-making article in 1882. 

Before the work of Porro and Sanger, the mortality following the 
operation was appalling. Meyer (1867) collected 1,605 cases from the 
literature with a mortality of 54 per cent.; while in 80 cases per¬ 
formed in the United States up to 1878, collected by Harris, 52.5 per 
cent, of the women died. According to Budin, not a single successful 
cesarean section was performed in Paris between the years 1787 and 
1876. Such poor results were obtained by physicians that Harris in 
1887 pointed out that the operation was more successful when performed 
by the patient herself, or when the abdomen was ripped open by the horn 
of an infuriated bull. He collected 9 such cases from the literature with 
5 recoveries, and stated, that out of 11 cesarean sections performed 
in the city of New York during the same period, only one patient re¬ 
covered. 

The hird period began with the year 1876, when Porro advised 
amputating the body of the uterus and stitching the cervical stump into 
the lower angle of the abdominal wound in order to lessen the danger 
from hemorrhage and infection. This procedure, being followed by 
very satisfactory results, soon became quite popular, so that in 1890 
Harris was able to collect 264 operations from the literature. Storer, 
of Boston, in 1868, amputated a pregnant myomatous uterus, with a 
fatal result, but, inasmuch as he did not appear to recognize the im¬ 
portance of the innovation, the credit for proposing it undoubtedly be¬ 
longs to Porro. 

Sanger, in 1882, revolutionized the cesarean section by directing 
attention to the necessity for the employment of uterine sutures. As 
the uterus was not sacrificed in this operation, it was designated as the 
conservative , in contra-distinction to the Porro cesarean section. With 
the increasing perfection of surgical technic, more and more satisfactory 
results were obtained from the former operation, while the latter became 
less popular. 

After the technic for supravaginal amputation of the myomatous 
uterus had become perfected, similar methods were applied to the Porro 
operation, the cervical stump being covered by a flap of peritoneum 
and dropped into the abdominal cavity; while in a small number of 
cases, particularly when the cervix was carcinomatous, the entire organ 


CESAREAN SECTION 


495 


was removed. The latter procedure, which was first attempted by 
Bischoff, has but a limited field of application. 

The fourth period began in 1907 when Frank of Cologne, who had 
become dissatisfied with the results following the classical conservative 
section, particularly in women who had been exposed to the possibility 
of infection prior to the operation, reported 13 cases upon which he 
had operated by a new method. In this procedure a transverse incision 
is made through the anterior abdominal wall several centimeters above 
the symphysis, and the peritoneum separated from the posterior surface 
of the bladder and the anterior surface of the lower uterine segment. 
After proper exposure, the latter is then incised transversely, the child 
is extracted by forceps, the placenta removed manually, and the wound 
closed. By this method the entire operation is done extraperitoneallv, 
and, according to its inventor, may be safely employed when conservative 
section would be contra-indicated. 

The procedure was enthusiastically taken up in Germany, where it 
was soon found that in many instances the separation of the peritoneum 
could not be readily effected, or that in so doing it was torn through, 
thereby depriving the operation of its chief supposed advantage. Con¬ 
sequently, Latzo, Sellheim and others proceeded to modify the operation, 
and to convert it into a suprasymphyseal transperitoneal cesarean sec¬ 
tion. For this purpose, after exposing the uterus by a transverse abdomi¬ 
nal incision, its peritoneal covering is incised from one round ligament to 
the other just above its reflexion over the bladder. The peritoneal flap 
is dissected up for a short distance, and is then tightly sutured to the 
margins of the parietal peritoneum. In this way the lower uterine 
segment is isolated from the general peritoneal cavity and the possibility 
of infection limited. After separating the bladder from the low. uterine 
segment, the latter is incised transversely, and after the child is ex¬ 
tracted, the wounds are closed. 

As more extended experience with each of these modifications was 
not altogether satisfactory, Doederlein resuscitated the operation of 
laparo-elytrotomy, which had been suggested by Philip Syng Physick 
and by Baudelocque in 1823, and rehabilitated by Gaillard Thomas in 
1871, to be afterward abandoned in favor of the classical cesarean sec¬ 
tion. After reporting 32 such operations, he in turn abandoned the 
procedure, as he found that the wound healing was complicated, that 
drainage was always required and that the operation was not available 
for use in infected patients. 

Ivronig was not satisfied with any of these modifications, and con¬ 
tended that their main advantage consisted not so much in avoiding the 
peritoneal cavity, as in opening the uterus through its thin lower seg¬ 
ment. To accomplish this, he cut through the vesical reflexion of the 
peritoneum, and separated it and the bladder from the lower uterine 
segment. The latter is then opened by a vertical median incision and 
the child extracted by forceps. After closing the uterine incision, it is 
then buried under the vesical peritoneum. A somewhat similar technic 
has been employed by Beck and DeLee with satisfactory results. 

Finally, the historical aspects of the question were carefully con- 


496 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


sidered by Kiistner, in his monograph which appeared in 1915. In it 
he also described his own modification of extraperitoneal section, based 
upon a personal experience of 112 operations. This modification will 
be considered in detail in the section upon operative technic, when its 
advantages and contra-indications will be discussed. 

Indications.—With the increasing perfection of surgical technic, and 
an erroneous idea of the safety of the operation, there seems to be a 
growing tendency to regard cesarean section as the simplest means of 
coping with most obstetrical difficulties. At the present time I consider 
that the operation is being abused, and that not a few patients are 
sacrificed to the furor operativus of obstetricians and general surgeons 
who are ignorant of the fundamental principles of the obstetric art. 
This being the case, the conscientious obstetrician should be particularly 
careful in the recognition of indications for cesarean section. 

The most frequent and important indication is afforded by pelves 
which are so contracted as to offer serious mechanical obstacle to labor. 
The pelvic indication may be either absolute or relative , the upper limits 
being a conjugata vera of 5 and 7.5 centimeters respectively. In the 
former, the contraction is so pronounced that the birth of a child of 
normal size cannot be effected by any other means; while in the latter, 
it is sufficiently marked to render spontaneous labor impossible, but per¬ 
mits delivery after craniotomy. 

In view of the excellent results which now follow cesarean section, 
and the fact that the spontaneous delivery of an ordinary full-term child 
is out of the question when the conjugata vera is less than 7.5 centi¬ 
meters, the upper limit for the absolute indication has been extended 
to that point, provided the child is alive, the patient is in ideal condi¬ 
tion and amid suitable surroundings for a major operation. 

Even when the pelvis falls within the so-called “border line” category 
—with an upper limit of 8.5 centimeters in flat and 9 centimeters in 
generally contracted pelves—the operation may likewise be indicated. 
In pelves of this character, however, the course of labor depends not 
merely upon the degree of pelvic contraction, but more particularly upon 
the size and consistency of the head and the character of the uterine 
contractions. Given two women with pelves and children of the same 
size, one may have a spontaneous and easy labor, while the other may 
require radical operative interference. In the latter event, the operation 
is undertaken primarily in the interests of the child, instead of resorting 
to high forceps, version, and craniotomy. 

Accordingly, in this class of cases, when examination at the end 
of pregnancy reveals the existence of serious disproportion between the 
size of the head and the pelvis, and particularly when the patient pre¬ 
sents a history of previous operative labors with dead children, classical 
conservative cesarean section should be performed at an appointed time 
before the onset of labor, or within a few hours thereafter, since the 
prognosis for the mother becomes more serious with every hour inter¬ 
ference is deferred. On the other hand, if not seen until late in labor, 
I believe that better results for the mother, and nearly as good results for 
the child, will be obtained by allowing the patient to go into the second 


CESAREAN SECTION 


497 


stage, and then resorting to pubiotomy or extraperitoneal cesarean sec¬ 
tion if engagement does not occur after several hours of strong pains, 
provided, of course, the patient is in good condition, and in the hands of 
a competent operator. By so doing nearly all the children and many 
more mothers will be saved than after a late conservative cesarean sec¬ 
tion. If, however, these conditions cannot be fulfilled, the patient should 
be allowed to continue in labor until a definite indication for its termi¬ 
nation arises, when craniotomy should be performed. 

Pelvic contraction involving the superior strait is not the only indi¬ 
cation for cesarean section, as in not a few cases abnormalities of the 
pelvic outlet likewise call for its performance. It is usually stated that 
a bisischial diameter of 7 centimeters or less affords a positive indica¬ 
tion, but it will be pointed out in the section upon funnel pelvis that 
this does not necessarily hold good. Such a measurement should, how¬ 
ever, be regarded as a danger signal, as it indicates so great a narrowing 
of the pubic arch that spontaneous labor cannot occur unless there be 
sufficient space between the bisischial diameter and the tip of the sacrum 
to permit the passage of the head. Accordingly, in such cases, the abso¬ 
lute necessity for interference will depend entirely upon the length of 
Klien’s posterior sagittal diameter of the inferior strait. Other pelvic 
deformities which occasionally necessitate the operation will be consid¬ 
ered in the chapters upon Contracted Pelves. 

Obstruction to labor, not due to pelvic contraction, occasionally 
affords an indication for the operation. Thus, myomata in the lower 
segment of the uterus, as well as ovarian and other tumors, may so block 
the pelvic canal as to render cesarean section imperative. The same may 
be said of certain cases of atresia following cicatricial contractions of the 
cervix or vagina. 

Carcinoma of the cervix occasionally results in the formation of such 
dense and rigid tissue that dilatation becomes impossible. In such cases 
cesarean section is demanded in the interests of both the child and 
mother, and should be supplemented by total hysterectomy, if the disease 
be not too far advanced. In rare instances malignant tumors of the 
rectum may so obstruct the pelvic canal as to render cesarean section 
imperative, and Nijhoff collected the literature upon the subject up to 
1905. As a curiosity, it may be mentioned that Jaschke has reported a 
case in which the pelvic cavity was so obstructed by a megacolon that 
cesarean section was necessary. 

Halbertsma, in 1899, suggested cesarean section as the best method 
of delivery in certain cases of eclampsia complicated by an undilated 
and rigid cervix, and since then it has been extensively employed in all 
parts of the world. In the future, however, I imagine that it will be 
used much less frequently for two reasons. In the first place, consid¬ 
erable skepticism has developed concerning the curative effect of rapid 
delivery in eclampsia; while in the second place the symposium upon the 
treatment of eclampsia before the British Congress of Obstetrics and 
Gynecology held in 1922, and which was based upon the consideration 
of 2,005 cases, showed that only accouchement force gave worse results 
than cesarean section. 


498 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


Dudley, in 1900, suggested the advisability of cesarean section in 
certain cases of placenta previa, and Kronig and others have adopted 
his views. While admitting that such a procedure may be justifiable in 
very rare instances, I agree with Holmes that it is usually unnecessary, 
and, if adopted in a large series of cases, would probably increase the 
mortality of the complication. 

Following the discovery that in premature separation of the normally 
implanted placenta the uterine musculature may be markedly disasso¬ 
ciated by hemorrhage, cesarean section appears to be the operation of 
choice in that condition whenever the cervix is not dilated. Further¬ 
more, as the organ sometimes fails to contract after it has been emptied, 
the operation in such circumstances should be completed by supravaginal 
hysterectomy. 

In certain cases of pregnancy complicated by uncompensated heart 
lesions, cesarean section often affords the most conservative method of 
effecting rapid delivery, and the uterus should be amputated upon 
its conclusion as the most satisfactory method for preventing the occur¬ 
rence of pregnancy in the future. 

Reynolds has advocated cesarean section in the absence of pelvic 
contraction, or of any other mechanical indication, in women who appear 
to be mentally or physically ill-equipped to bear the strain of childbear¬ 
ing. Other writers have recommended its performance as a means of 
overcoming dystocia due to face, brow or transverse presentations; while 
still others have taken the extreme ground that it may even be justifiable 
in breech or obliquely posterior occipital presentations. While it may 
be admitted that in peculiar circumstances such indications may occa¬ 
sionally hold good, I cannot but feel that their advocacy has done great 
harm, and has afforded poorly trained physicians justification for reck¬ 
less and unnecessary operating. 

As it is generally believed that the cicatrix following a cesarean sec¬ 
tion represents a locus minoris resistentiae and may rupture during a 
subsequent pregnancy, many writers have laid down the dictum—“once 
a cesarean, always a cesarean.” As will be pointed out in the appropriate 
place, I do not entirely agree with such teaching. Naturally such a 
uterus is less efficient than one which has never been incised, and to my 
mind that fact should be regarded as a potent argument against the 
use of cesarean section for non-pelvic indications, except in the most 
pressing conditions. 

Contra-indications.—Except in the presence of an absolute indication, 
cesarean section should never be performed when the child is dead or in 
serious danger. It is likewise contra-indicated when the mother is in¬ 
fected, in poor condition, or among surroundings which render an 
aseptic operation impracticable. In such circumstances, craniotomy is 
the operation of choice, and cesarean section should not be undertaken 
unless a living child is earnestly desired; and then only after the risks 
incident to it have been clearly explained to a responsible member of 
the family. Again, the classical operation is contra-indicated when the 
patient has been long in labor or subjected to repeated vaginal examina¬ 
tions by those whose technic is questionable, even though no signs of 


CESAREAN SECTION 


499 


infection are apparent at the time. If, however, the operation should be 
decided upon in the presence of such risks/the body of the uterus should 
be removed after delivery of the child. 

Operative Technic.— (a) Conservative Cesarean Section. —The opera¬ 
tion will give almost ideal results if performed at an appointed time, 
a day or so prior to the end of pregnancy, or within a few hours after 
the onset of labor; whereas the prognosis becomes progressively worse 
' for every hour it is deferred. 

When the operation can he performed at a fixed time, the patient 
should be prepared exactly as for an ordinary abdominal operation. On 
the night before she should receive a full |*batli and the abdomen and 
pubic hairs should be shaved. The bowels should be evacuated by an 
appropriate cathartic, and an enema given a few hours before she is 
put upon the table. If the patient is not seen until labor has set in, 
similar preparations should be made, except that the hath and the admin¬ 
istration of a cathartic must, of course, be dispensed with. 

Just before the beginning of the operation., the bladder is catheterized 
and the abdomen disinfected by means of tincture of iodin and alcohol. 
The woman being in the dorsal position, the entire body, except the 
field of operation, is covered with sterile towels. In order to insure 
satisfactory contraction and retraction of the uterus, one c.c. of p.ituitrin 
should be administered hypodermically just after the abdominal incision 
is made. 

In addition to the operator, four assistants are needed, one to give 
the anesthetic, one to assist directly at the wound, and two to handle 
the instruments. With the exception of the anesthetist, all should wear 
rubber gloves, and suitable sterile gowns and masks. A competent 
person should be charged with the reception and care of the child and 
receive careful instructions as to the best method of resuscitating it if 
necessary. The following instruments are required: 1 scalpel, 1 long 
blunt-pointed scissors, 2 dissecting forceps, 12 short and 6 long artery 
clamps, abdominal retractors, a needle-holder and appropriate needles, 
as well as the usual sterile dressings, suture materials, and gauze sponges. 

An incision 15 centimeters long should be made in the linea alba, 
beginning just below the umbilicus. The abdominal walls are usually 
very thin and bleed little, rarely more than two or three clamps being 
required to check hemorrhage. The uterus is found directly beneath 
the incision. If deflected to one side, its long axis should be brought into 
correspondence with the abdominal incision, and gauze packs, moistened 
with sterile salt solution, inserted between it and the margins of the 
abdominal incision, so that the possibility of contaminating the peri¬ 
toneal cavity may be reduced to a minimum. If there is no likelihood 
of infection, the uterus should be opened in situ; otherwise the incision 
should be sufficiently enlarged upwards to permit delivery of the organ 
from the abdominal cavity, and in this contingency it should not be cut 
into until the edges of the wound have been clamped together above the 
cervix and covered with sterile towels. 

In either event the anterior surface of the uterus is opened longi¬ 
tudinally along its middle line. This is best accomplished by making 



500 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 



Fig. 427. —Conservative Cesarean Section. 

Diagram showing location and extent of the abdominal and uterine incision. Distended 

faetal membranes visible through uterine incision. 


an incision a few centimeters long with a scalpel, and then rapidly 
enlarging it with the scissors to 15 centimeters. The membranes are 
then ruptured, the child is seized by one foot and extracted. Two clamps 
are applied to the cord, which is cut between them, and the child handed 
to an assistant. This takes but a short time, and it is rare for more 
than ninety seconds to elapse between the beginning of the operation 








CESAREAN SECTION 


501 


and the birth of the child. Many authorities recommend that an at¬ 
tempt be made to locate the position of the placenta beforehand, so that 
the incision may be made in such away as to avoid it. This, however, 
is not necessary. If the placenta lies under the incision, it should 
be rapidly cut through or pushed to one side and the child extracted. 
This is accompanied by a slight increase of hemorrhage, but as the 
bleeding is only momentary, it is without significance. Immediately 
after the delivery of the child, the uterus contracts down and hemorrhage 
practically ceases. The uterus should then be delivered through the 



Fig. 428. —Conservative Cesarean Section. 

Contracted Uterus Delivered through the Abdominal Wound and Packed off with Gauze 

Compresses. Placenta still in situ. X Xb 

abdominal incision, and the peritoneal cavity posterior to it protected by 
gauze napkins. If the placenta and membranes have not become sepa¬ 
rated spontaneously, they should be peeled off and removed with the 
hand, care being taken that no shreds of membranes are left behind. 
Disinfection of the uterine cavity is not necessary. Even when the opera¬ 
tion is undertaken before the onset of labor, it is not necessary to dilate 
the cervix artificially, as the canal is always sufficiently patulous to permit 
free drainage. 

To prevent hemorrhage, Litzmann recommended that an elastic 
ligature be applied about the cervix before opening the uterus. This is, 
however, an unnecessary precaution; nor is it devoid of danger, as the 






502 , CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


prolonged compression predisposes to uterine atony and hemorrhage 
afterward. .If, however, there is considerable' loss of blood after the 
delivery of the'child,-the assistant should grasp the cervix firmly between 
his fingers-. and'--thus compress the uterine-arteries. This effectually 
controls hemorrhage and is preferable to the employment of a rubber 
ligature..' . . . ' . .. . ■ - ; 

Ffitsch, in 18.9^,-proposed opening into tile uterus through a trans¬ 
verse incision over'the fundus, instead of* by the usual method, holding 



Fig. 429 .— Conservative Cesarean Section. 

Placenta has been delivered and deep sutures laid. The upper sketch shows the bite of 
the suture which avoids the decidua and the external layer of muscles. X 


that, the course of blood vessels in that location being parallel to the 
incision, the hemorrhage would therefore be less. His proposal was at 
once tested by many operators. The results were excellent, but not 
better than those following the more usual incision. 

There would appear to be no advantage in adopting Fritsclrs sug¬ 
gestion, except perhaps in the small number of cases in which it is desired 
to sterilize the patient by excising the tubes. It is urged that the fundal 
wound is less likelv to be followed by adhesions between the uterus and 
the anterior abdominal wall. This is no doubt correct, but at the same 




CESAREAN SECTION 


503 


time, should infection occur with the transverse incisuSnp Virulent imate^ 
rial is more liable to gain access to the general peritoneal cavity ;, while, 
if it occurs with the longitudinal incision, the abscess has inofe chance 
of opening through the abdominal wound. ' : 

Asa B. Davis has recommended that the abdominal incision be made 
entirely ado's e the umbilicus, and that the uterus be incised high up 
coiresponding to it. Notwithstanding his advocacy of the high incision, 



Fig. 430 . —Conservative Cesarean Section. 

The deep sutures have been tied and cut, and the superficial layer of muscle and periton¬ 
eum are being brought together by a continuous suture. The upper sketch gives 
further details. 


my results have been so satisfactory with the method just outlined that 
I see no reason for changing it. 

After any of these methods of incision the uterine wound is closed by 
deep and superficial formol or chromicized catgut sutures. The former 
are placed at intervals of about 1 centimeter. They are introduced 
by means of a large curved needle just beneath the thin superficial 
muscular layer, and extend through the entire thickness of the muscu- 
laris, avoiding the decidua. They are then tied and cut short, after 
which the superficial muscular layer and peritoneum are brought together 






504 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


over them by a continuous suture. This is readily accomplished, and 
is preferable to the original procedure of Sanger, in which small flaps 
of peritoneum were formed by excising a thin layer of muscle from 
either side of the wound. Any blood which may have escaped into the 
pelvic cavity is then carefully sponged out, and the abdominal wound 
closed. This is best accomplished by suturing the peritoneum, muscles, 
fascia, and skin in separate layers. 

( b ) Porro Cesarean Section .—Until after the delivery of the child, 
the operative steps are identical whether the uterus is to be retained 
or its body is to be amputated. If, however, the latter is to be done, 
it is unnecessary to remove the placenta. In the typical Porro operation, 
the technic is as follows: As soon as the child is delivered an elastic 
ligature is tightly tied around the upper portion of the cervix. The 
infundibulopelvic ligaments are then ligated and cut through, after 
which the uterus is amputated a short distance above the rubber ligature. 
To prevent the stump from slipping backward, a long knitting needle 
is passed through it and allowed to rest upon the abdominal walls. The 
stump is then sewed into the lower angle of the abdominal wound, the 
remainder being closed in the usual manner. Within a short time the 
stump and elastic ligature slough off, leaving a depressed wound which 
heals by granulation. This operation is readily performed, but is rarely 
employed at present, because of the complicated healing, and the in¬ 
drawn scar which results. 

At present, when it is desirable to remove the body of the uterus, 
practically the same technic is employed as in an ordinary supravaginal 
hysterectomy with retention of the ovaries, and is greatly facilitated by 
placing the patient in the Trendelenburg posture. After the uterus has 
been delivered from the abdominal cavity, the tubes, ovarian and round 
ligaments on either side are ligated a short distance from the uterus, 
clamped still nearer to it, and severed. With a single stroke of the 
scissors the broad ligament on either side is cut through down to its 
base. An elliptical incision is then made through the peritoneum on 
the anterior surface of the uterus, just above the bladder, and a peri¬ 
toneal flap rapidly peeled off by means of a piece of gauze applied around 
the end of the finger or the handle of a scalpel. The uterine arteries 
are then isolated, ligated, and severed, after which the body of the uterus 
is amputated. The cervical stump is brought together by the necessary 
number of catgut sutures, covered by the peritoneal flap, and is then 
dropped into the pelvic cavity. The openings in the broad ligaments 
are closed by continuous catgut sutures, the pelvic cavity is sponged out, 
and the abdominal wound closed (Figs. 431 and 432). 

The operation is readily performed, and can be completed in as short 
a time as a conservative cesarean section; for, owing to the laxness of 
the pelvic floor and the abdominal walls, the upper portion of the cervix 
can be brought through the incision and the entire operation completed 
upon the surface of the abdomen. 

(c) Total Hysterectomy .—Bischoff was the first to remove the entire 
uterus after cesarean section, and, under thoroughly aseptic conditions, 
the operation gives satisfactory results. The technic is identical with 


CESAREAN SECTION 


505 


that employed in supravaginal amputation of the uterus, except that 
after the ligation of the uterine arteries the vaginal vault is cut through 
and the entire uterus removed, after which the opening in the vagina 
is closed with catgut and the broad ligament wounds are sutured. Total 



Fig. 431.—Cesarean Section Followed by Supravaginal Hysterectomy, with 
Retention of Tubes and Ovaries. Placenta Still in Utero. 

1 , Clamp applied to round ligament; 2 , clamp applied to proximal end of tube and broad 
ligament; 8 , anterior peritoneal flap; 4 , clamp applied to proximal end of uterine 
artery; 5 , transverse incision through cervix. X 1. 

hysterectomy is rarely indicated except in cancer of the uterus, or in 
occasional cases of infection. 

In all forms of cesarean section, as well as in all other laparotomies, 
loose sponges should not be used after the peritoneal incision is made. 
From then on, only sponge holders should be employed, and care should 
be taken to see that they hold the sponges firmly. Furthermore, com- 













506 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


presses or pads should be used only when they are sewed to a piece of 
tape to whose free end an artery clamp is attached. They should be 
counted at the beginning of the operation and before closing the peri¬ 
toneal wound. Failure to observe these precautions will sooner or later 
result in a sponge or pad being left within the abdominal cavity, which 
is not only an uncomfortable accident for the patient, but may lead to 
serious medicolegal complications for the operator. 



- •*» 






'Yr 


Fig. 432.—Cesarean Section Followed by Supravaginal Hysterectomy. 

Note the tubes and ovaries in situ; the method of suturing the cervical stump, and the 
broad ligament wound which will later be closed by a continuous suture. X 1. 


( d ) Extrap eritoneal Cesarean Section. —In appropriate cases verv 
satisfactory results may be obtained by Kiistner’s modification of this 
operation. Its technic is as follows: The patient, who should he well 
advanced in labor, is placed in the Trendelenburg posture and 150 c.cm. 
of salt solution are introduced into the bladder, if it is empty. A vertical 
incision is made through the abdominal wall at the outer margin of the 





CESAREAN SECTION 


507 


left rectus muscle, extending 12 centimeters upward from Poupart’s 
ligament. Alter cutting through the lower layer of fascia, and being 

°P eniD g the peritoneal cavity, the reflexion of the visceral 




m 





S? 





yf 








B 5* R i 


J 




■V 

*VA ->^ v ‘ * Si 


1.' ■ - 

vt ^ *> 

Mllll 


f - 

:, •-v-V 



gUf^/vP: 

TwHWsBfej 


^.*gS£.' " : 

> • V ’f* *- * 


■ 


m 


t\\- 


i •'■\Al 

^vl 




Fig. 433. —Extraperitoneal Cesarean Section. Diagram Showing 

Direction of Skin Incision. 

The dotted line to its right indicates the outer margin of rectus muscle. 

peritoneum and the lateral aspect of the bladder become visible. By means 
of scissors and gauze sponges the left side of the bladder is dissected 
off from the anterior surface of the lower uterine segment, and drawn 
beyond the midline by a suitable retractor. The peritoneal reflexion is 





508 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


then pushed upward as far as possible and the anterior surface of the 
lower uterine segment exposed by means of retractors. This is then 
incised in the midline, and the child extracted by forceps. As the 
lower uterine segment is never more than a few millimeters thick, care 
must be exercised in incising it in order not to injure the foetus. After 
the placenta has been removed, the uterine incision is closed in two 
layers by continuous catgut sutures, and the various structures of the 
abdominal wall are united in appropriate layers, after a small gauze 



Fig. 434. —Extraperitoneal Cesarean Section. Abdominal Muscles Separated 
by Blunt Dissection, and Underlying Structures Exposed. 

a, lower uterine segment; b, peritoneal reflexion; c, bladder partly freed and drawn 

toward midline of body. X %• 

drain has been inserted into the deepest part of the wound and brought 
out through the lower end of the incision (Figs. 433 to 436) . 

There is usually comparatively slight hemorrhage, and, if the dis¬ 
section is carefully done, the danger of wounding the bladder or of 
opening the peritoneal cavity is not great. During the separation of the 
bladder, the left ureter and uterine artery are frequently visible, and 
consequently are but little exposd to injury. The employment of the 
Trendelenburg posture is almost imperative, as without it the difficulty 
of the operation is greatly increased. 







CESAREAN SECTION 


509 


Choice of Operation.—When the operation is to be performed at an 
appointed time, or upon patients who have not been exposed to the pos¬ 
sibility of infection, the classical cesarean section is the operation of 
choice; whereas, when the operation is undertaken later in labor, or 
upon women who have been examined by those whose technic is open to 
suspicion, better results will probably be obtained by the extraperitoneal 
method. I am not convinced of the advantages of the various modifica- 



Fig. 435. —Extraperitoneal Cesarean Section. Final Exposure and Incision of 

Lower Uterine Segment. 


Note thinness of uterine wall, with the foetal membranes protruding through the incision. 

X 


tions of the low cervical operation; and, as my experience with the 
classical operation has been so satisfactory, I have left to others the 
development of its technic. On the other hand, if the patient is already 
frankly infected, supravaginal hysterectomy should be done, as it alone 
offers a prospect of satisfactory results. When the uterus is the seat of 
tumor formation, as well as in those cases in which osteomalacia is the 
cause of the pelvic deformity, or in which persistent hemorrhage result¬ 
ing from uterine atony complicates the conservative operation, supra¬ 
vaginal hysterectomy is also the operation of choice. 










510 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


While I am not able to share the enthusiasm of Iviistner concerning 
extraperitoneal cesarean section, who in 1920 reported 183 operations 
with four deaths, I admit that it constitutes an important addition to 
our resources, in that it makes possible the performance of cesarean sec¬ 
tion in a certain number of cases in which pubiotomy was formerly the 
operation of choice. On the other hand, I do not believe that it should 
be regarded as a competitor with the classical conservative opeiation 
under appropriate conditions for the following reasons: First, that its 
technic is so difficult that it can be performed only by practiced operators; 



Fig. 436. —Extraperitoneal Cesarean Section. Suture of Uterine Incision 
After Delivery of Child and Placenta. X %. 

second, that it is associated with considerable risk of injury to the 
bladder; third, that it always requires drainage of the prevesical space, 
and is sometimes complicated by extensive suppuration of the pelvic 
connective tissue; and lastly, that the adhesions following it render a 
repetition of the operation impossible in subsequent labors. 

In doing a cesarean section, the question often arises as to the 
advisability of sterilizing the patient so as to avoid the possibility of 
future conception. This can be effected by supravaginal amputation of 
the uterus, by excising the tubes, or removing the ovaries.. 

I consider that it is best effected by supravaginal amputation of the 
uterus, but with preservation of the tubes and ovaries, in order that 











CESAREAN SECTION 


511 


the inconveniences attending a premature menopause may be avoided. 
This belief is based upon the fact that the uterus is useless if further 
pregnancies are out of the question, but more particularly because supra¬ 
vaginal amputation is safer and can be done more rapidly than the 
conservative operation followed by excision of the tubes. Furthermore, 
the convalescence following the former operation is more satisfactory, 
the difference being quite as marked as that observed in the treatment 
of uterine myomata by supravaginal amputation or by myomectomy, 
respectively. 

It was formerly believed that sterilization could be effected by 
ligating the proximal end of either tube; but experience has shown that 
the ligatures eventually cut through or become absorbed, and that the 
lumen of the tube may subsequently become restored, and with it the 
possibility of future pregnancy. It was next suggested that the object 
might be accomplished by applying a double ligature to each tube and 
excising the portion between them; but the experiments of Fraenkel 
upon animals, and the experience of Zweifel, and Cripps and Williamson 
upon the living woman, have shown that even these measures do not 
insure against conception, since the ligatures may be absorbed and the 
cut ends of the tube become united. In order, therefore, to effect per¬ 
manent sterilization by an operation upon the tubes, their proximal ends 
must be buried between folds of the broad ligaments, or they must be 
excised from the uterine cornua by wedge-shaped incisions and the 
wounds closed by sutures. The former procedure is preferable, is readily 
effected, and I now employ it as the operation of choice, unless amputa¬ 
tion of the uterus is indicated for some other reason. 

Sterilization should not be attempted by the removal of the ovaries, 
for the reason that the retracting uterus may exert such tension upon 
the pedicles that the sutures may slip and fatal hemorrhage result, but 
more particularly because their internal secretion is necessary to the 
future well-being of the patient. 

The opinion of those authorities who consider that sterilization should 
form an integral part of every cesarean section is certainly open to ques¬ 
tion. If the patient is intelligent, the decision should be left to her and 
her family, but at the same time the undesirability of a one child mar¬ 
riage should be strongly urged; whereas with the ignorant it is incum¬ 
bent upon the physician to do what he thinks is best under the circum¬ 
stances. Personally, I am unwilling to sterilize any patient at the ffrst 
operation, unless operative complications necessitate the removal of the 
uterus, or unless the patient comes from a district where proper operative 
help might not be available in a future pregnancy. On the other hand, 
if she is weak-minded or diseased and is liable to become a public charge, 
the operation is justifiable. In general, with pauper patients, it is my 
practice to effect sterilization at the third cesarean section. 

Prognosis.—When considering the history of cesarean section, refer¬ 
ence was made to the mortality attending it in former times. Since 
the rehabilitation of the conservative operation by Sanger in 1882, and 
the constant advance in aseptic technic, there has been a corresponding 
steady improvement in the results: Caruso collected from the literature 


512 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


135 operations performed between the years 1882 and 1888, with a mor¬ 
tality of 25.56 per cent. Since then the death rate has gradually fallen 
and many writers would have us believe that it is as low as one or two 
per cent. While this is correct for selected cases in the hands of experts, 
I imagine that it would be found to be in the neighborhood of ten per 
cent, if the actual results for the entire country could be ascertained. 

That the mortality is generally underestimated is shown by the report 
of the committee on material and infant welfare of the Massachusetts 
Medical Society. This committee, in an attempt to ascertain why the 
mortality from childbirth was greater in 1920 than ten years previously, 
analyzed the deaths occurring in Massachusetts during the year 1921. 
After making certain justifiable deductions, it found that 525 deaths had 
occurred—a ratio of 1 to every 182 labors—and that one-sixth of the 
entire number had followed cesarean section, one-half of these being due 
to infection. In other words, after frank puerperal septicemia, cesarean 
section constituted the second most common cause for death in childbirth 
in Massachusetts. One of the members of the Committee informed me 
that he was convinced that this excessive mortality was in great part due 
to the performance of the operation by surgeons who did not appreciate 
its dangers, and who operated upon patients at other than the optimum 
time. 

Routh in 1911 reported a mortality of 9.7 per cent, in 1,058 classical 
sections performed by 100 British operators; while Eardley Holland 
reported one of 4 per cent, in a collective investigation based upon 4,197 
operations performed in 37 British hospitals during the following ten 
years. 

On the other hand, individual operators may report large series of 
cases with little or no mortality. Thus, Zweifel recorded 76 cesarean 
sections with 1, and Leopold 70 operations, with no deaths. No matter 
how good the operator, or how perfect his technic, it would appear that 
the mortality, even in apparently uninfected women, will be low only 
when the operation is done at an appointed time before the onset of labor 
or within a few hours after the first pains, and that it will increase 
progressively with every additional hour of delay. Reynolds first appre¬ 
ciated this fact in 1907, and upon analyzing 289 cases, according as the 
operations were done before labor, or early or late in labor, found a mor¬ 
tality of 1.2, 3.8 and 12 per cent, respectively. Routh arrived at almost 
identical conclusions, and noted a death rate of 2.9 per cent, when the 
operation was performed before rupture of the membranes, 10.8 per cent, 
after their rupture, and 34.3 per cent, following repeated examination or 
previous attempts at delivery. The following table from HollamTs article 
based upon 1953 sections for contracted pelvis, shows that the results 
have scarcely changed during the succeeding ten years. 


Time of operation 

Before labor.. 

Early in labor. 

Late in labor. 

After induction of labor. 

After attempts at delivery by forceps, etc. 


Total 


No. cases 

Mortality 

1202 

1 

6 per cent. 

389 

1 

,8 

220 

10 

0 

35 

14 

0 

107 

27 

0 

1953 

4. 

3 per cent. 










CESAREAN SECTION 


513 


My own experience, which is based upon 253 operations performed by 
myself or my assistants at the Johns Hopkins Hospital up to April 15, 
1923, has been similar. Our material may be divided into two groups: 
the first 50, and the succeeding 203 operations, with a gross mortality of 
12 and 2.45 per cent, respectively. In the first period the operation was 
performed at any time, and frequently after a prolonged test of the 
second stage; while in the second period it was done preferably at an 
appointed time before, or within a few hours after, the onset of labor, and 
the body of the uterus was amputated if the patient presented signs of 
infection or if attempts at delivery had been made. Of the 5 deaths 
occurring in the latter period, only two were due to infection, so that in 
the last 203 cases the mortality from that cause has been 1 per cent. 
The radical change in my point of view is well exemplified by articles 
which I wrote in 1901 and 1921 respectively. 

As the operative technic was the same, the element of time must be 
regarded as the essential factor of difference in the two series. That this 
is correct, was shown by the histological study of uteri, which were 
amputated at the conclusion of the section. Naturally, if the patient 
presented signs of intrapartum infection, bacteria were found in the 
lining of the uterus, but we were at first surprised at finding them as 
well in patients who had been operated upoji late in labor without such 
signs. As our experience became greater, and as we found that the 
bacteria were limited to the cervical mucosa, to the decidua lining the 
lower part of the uterus, or had extended throughout the entire mem¬ 
brane, according to the length of time which had elapsed after rupture 
of the membranes, the idea of ascending infection developed. In 
such circumstances, the infection has every chance to extend in the 
incised and involuting organ; whereas, if the body of the uterus is 
amputated, the focus of infection is removed, and the convalescence 
is usually ideal. 

Accordingly, one can reckon upon a mortality of 1 or 2 per cent, 
when the operation is done early and one of 10 or more per cent, when 
it has been preceded by a long second stage. For these reasons, the 
classical operation is justifiable solely in the interests of the child in the 
one case, but not in the other. If, however, the patient is not seen until 
late in labor, and interference is demanded, the extraperitoneal operation 
or pubiotomy becomes the procedure of choice, unless one is willing to 
sacrifice the uterus. Finally, it should be remembered that when any 
type of cesarean section is performed by inexperienced operators upon 
patients in poor conditions and among unhygienic conditions the results 
will be disastrous. 

The mortality following the typical Porro operation likewise shows a 
corresponding improvement. Thus, the tabulation by Harris of 441 
such operations performed between the years 1873 and 1891 showed a 
decrease from 60 per cent, at the beginning of the period to 22.8 per 
cent, at its end. 

During the same period the mortality following supravaginal hyster¬ 
ectomy with retroperitoneal treatment of the stump was reduced from 
85.7 per cent, to a few per cent. In 177 operations more recently reported 




514 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


by Chrobak, Schauta, Leopold, and Braun the gross mortality was 10.3 
pe? cent., which became reduced to 2.5 per cent, on deducting the cases 
which were infected prior to operation. In our service the results were 
still better, as only three deaths occurred in 70 operations, and none of 
them were due to infection, notwithstanding the fact that in many 
instances intrapartum infection afforded the indication for operating, and 
the presence of streptococci could be demonstrated in the amputated 
uterus. Our results were critically analyzed by Harris in 1922. 

This marvelous diminution in mortality is due to several factors. 
Primarily, of course, it must be attributed to the ever-increasing per¬ 
fection of aseptic technic. At the same time, careful examination of the 
patient and the evaluation of the degree of disproportion in contracted 
pelvis during the last weeks of pregnancy have contributed markedly to 
the improvement, as they make it possible to do the operation at an 
appointed time before the onset of labor, instead of only after the failure 
of other methods of delivery. 

It is too early to express a definite verdict concerning the mortality 
of the various recent modifications of cesarean section, but the fact that 
so many have been proposed makes it evident that the results are not 
universally satisfactory. Kiitner reports 4 deaths in 183 operations per¬ 
formed by his extraperitoneal operation, and states that one-half of the 
patients were in such condition that he would have hesitated to employ 
the classical operation. My own experience and the reports of other 
operators lead me to conclude that such results are exceptional, and 
cannot be expected in frankly infected patients, for whose benefit such 
operations were first proposed. 

Repeated Cesarean Section. —The performance of conservative ce¬ 
sarean section does not interfere with future conception, as is shown by 
the fact that even in pre-antiseptic times not a few instances were 
reported in which the same woman had repeatedly been subjected to the 
operation. Nor does it necessarily affect recovery at a subsequent opera¬ 
tion. I have done four successful cesarean sections upon the same 
patient, and Ahlfeld, Birnbaum and others have reported cases of women 
who underwent five sections. With the increased employment of the 
operation, repeated cesarean sections are frequently necessary, Gamble, 
in 1922, having reported 51 such cases from our service; while as early 
as 1906 Friihinsholz was able to collect 52 instances in which the opera¬ 
tion had been performed for a third time upon the same patient. 

The occurrence of pregnancy after a cesarean section is not devoid 
of danger, as the recent literature indicates that rupture occurs through 
site of the previous incision in from 1 to 4 per cent, of the sub¬ 
sequent gestations, and certain authors consider it so real a danger that 
they have laid down the dictum, ‘‘Once a cesarean, always a cesarean/’ 
This is an exaggeration, and is in part based upon the belief that the 
uterine incision heals by the formation of scar-tissue—whence the term 
cicatrix—and that the newly found connective-tissue stretches and some 
times yields when the uterus becomes distended. That such a belief is 
erroneous is shown in three ways. First, inspection of the unopened 
uterus at the time of repeated sections usually shows no trace of the 


CESAREAN SECTION 515 

former incision, or, if present, it appears as an almost invisible linear 
scar. Second, when the body of the uterus has been amputated, no scar 



Fig. 437. —Section through Site of Previous Cesarean Section, Showing Interlac¬ 
ing Muscle, and Absence of Scar Tissue. 


is visible after hardening, or at most a shallow vertical furrow is present 
upon the external and internal surfaces of the anterior uterine wall, 





516 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 

while between them no trace of scar tissue is apparent. Third, and most 
important, histological examination of the site of the incision, shows that 
the uterus, just as all other organs made up of non-striated muscle, 
heals by regeneration of the muscle fibers and not by scar tissue. Fig. 
437, which represents a microscopic section through the site of the 
previous incision in a uterus removed at a second cesarean section, 
shows the furrows above referred to and demonstrates that the tissue 
between them is made up of muscle fibers which interlace in such a way 
as to give no evidence of ever having been injured. 

Even when the healing has been so imperfect that marked thinning 
has resulted, the tissue which remains is almost entirely muscular in 
character. Consequently, I believe when the incision has been properly 
sutured that the risk of subsequent rupture is minimal, provided infec¬ 
tion has not occurred. That rupture, nevertheless, sometimes occurs 
is shown by the fact that Brodhead was able to collect 20 such accidents 
in 1906, which were increased to 97 by Holland in 1920. I have per¬ 
sonally seen two cases, one of which occurred in a patient whose original 
section had been done in the service. The possible occurrence of rupture 
should always be considered in connection with the employment of 
cesarean section for other than pelvic indications, as thereafter the uterus 
must be considered as a “locus minoris resistentiae.” In such cases a 
normal spontaneous termination should be anticipated in subsequent 
labors, unless the puerperium had been febrile, but it is nevertheless 
advisable for the patient to be under observation in a hospital so that 
immediate laparotomy can be undertaken should rupture occur. 

It is also stated that the adhesions which frequently form between 
the uterus and the anterior uterine wall, as well as with the omentum 
and occasionally with the intestines, sometimes exert a deleterious in¬ 
fluence in subsequent pregnancies. Aside, however, from the discomfort 
incident to their stretching, no serious consequences follow; although at 
subsequent operations they may seriously complicate the operative tech¬ 
nic. In earlier days, the formation of dense adhesions was considered 
advantageous, as they were sometimes so extensive that subsequent sec¬ 
tions could be done without opening into the general peritoneal cavity. 
At present, however, they are no longer so considered, as it is necessary 
to get rid of them in order to secure ideal closure of the new incision. 

Vaginal cesarean section has already been considered in the chapter 
upon accouchement force. 

Postmortem Cesarean Section. —From the earliest times, when a pa¬ 
tient died undelivered in the neighborhood of full term, cesarean section 
was sometimes performed immediately after the death, in the hope of 
saving the life of the child. The number of children rescued by the 
procedure, however, has always been very small. In view of this fact, 
and the abhorrence in which it is more or less justly held by the laity, 
I do not consider that it should be recommended, more satisfactorv 
results being obtainable from accouchement force, especially as the cervix 
just before or immediately after death is more readily dilatable than at 
other times. 


SYMPHYSEOTOMY 


517 


SYMPHYSEOTOMY 

By symphyseotomy is meant the division of the pubic joint in order 
to bring about an increase in the capacity of a contracted pelvis suffi¬ 
cient to permit the passage of a living child. 

J. It. Sigault first performed the operation in 1777, and thereby 
successfully delivered a certain Madame Suchot, of Paris, who had a 
rhachitic pelvis with a conjugata vera of 6.5 centimeters and had 
previously given birth to four dead children. The procedure created a 
great sensation, though when the patient was exhibited before the Faculty 
of Medicine two months later she walked with considerable difficulty, 
and had a urinary fistula from which she never recovered. 

The operation was taken up with great enthusiasm, and was per¬ 
formed upon 11 patients within the first year after SigaulPs report. 
Opposition to it, however, soon developed, Baudelocque denouncing it as 
a ‘‘murderous and unphilosophical procedure”; and the discussion as to 
its merits waxed so bitter that the Parisian physicians became divided 
into two groups, cesareans and symphyseans. As a result of poor technic 
and its employment in unsuitable cases, symphyseotomy soon fell into 
disrepute and was forgotten except in Italy, where it was performed 
sporadically until the year 1858. 

The operation was rehabilitated in 1866 by Morisani, of Naples, who 
obtained fairly satisfactory results by its means, being able to report 50 
operations with 40 recoveries to the International Medical Congress in 
1881. It was reintroduced into France by Spinelli in 1891, who im¬ 
pressed its merits so strongly upon Pinard that he took it up and has 
since been its most enthusiastic advocate, being able to report in 1900 
that 100 symphyseotomies had been performed in his clinic. The ana¬ 
tomical aspects of symphyseotomy were carefully studied by Farabeuf, 
who accurately demonstrated its theoretical possibilities. Dr. Pobert P. 
Harris played a prominent part in directing attention to the operation in 
this country by a paper entitled The Remarkable Results of Antiseptic 
Symphyseotomy, read at the 1892 meeting of the American Gynecolog¬ 
ical Society. Stimulated by this report, Jewett, a few months later, 
performed the first operation in America, and was soon followed by many 
others. Symphyseotomy was the main theme of discussion at the German 
Gynecological Congress in 1893, the International Medical Congress in 
1897, and the Obstetrical Society of France in 1899, but in recent years 
it has practically been abandoned in favor of pubiotomy. 

As soon as the symphysis is cut through, the ends of the pubic bones 
gape from 3 to 6 centimeters. Owing to the structure of the sacro-iliac 
joints, the ossa innominata flare outward, while the tips of the pubic 
bones become depressed downward. As a result of these changes the 
capacity of the pelvic canal becomes considerably increased, particularly 
in its transverse and oblique, and less so in its anteroposterior, diameters. 
It is usually stated that the conjugata vera becomes 2 millimeters longer 
for each centimeter of separation at the symphysis. As the latter may 
amount to 6 or 6.5 centimeters without imperiling the integrity of the 
sacro-iliac joints, the increase would aggregate 12 or 13 millimeters. 


518 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


According to Farabeuf this estimate is not strictly correct, as the 
increase varies with the size of the pelvis, being 13 millimeters when 
the true conjugate measures 6 centimeters, and 10 millimeters when it 
measures 9 centimeters. This, however, does not represent the actual 
enlargement of the superior strait from an obstetrical point of view; 
for, as Farabeuf has pointed out, one of the parietal bosses tits into the 
opening between the gaping pubic bones, thereby considerably increasing 
the space available for the passage of the head. Doderlein has calculated 
that when the pubic bones gape 6 to 7 centimeters the area of the 
superior strait is increased by one half. 

As the results following symphyseotomy by the open method event¬ 
ually proved disappointing, and as those following cesarean section were 
constantly improving, the operation again fell into desuetude and is 



Fig. 438. —Diagram Showing Effect of Symphyseotomy (Farabeuf). 


now rarely resorted to, except by a few operators who employ a sub¬ 
cutaneous technic, such as Zweifel, Frank, and Schwartz, the latter having 
reported 113 cases with only three maternal deaths. For these reasons 
the indications and technic of the operation will not be considered, more 
particularly as what will be said in the following section concerning 
pubiotomy will apply to subcutaneous symphyseotomy as well. 

PUBIOTOMY 

This operation, which is more properly designated as hebotomy or 
hebosteotomy (from to rrjs rjftrjs oo-crow), consists in obtaining a tem¬ 
porary enlargement of the pelvis by severing the pubic bone to one side 
of the symphysis by means of a Gigli saw. 

History.—In 1893 Gigli stated that from a surgical point of view 
there were two serious fallacies in the operation of symphyseotomy. In 
the first place, the wound through the cartilage was very prone to in- 









PUBIOTOMY 519 

fection, and healed but slowly, and, secondly, the incision in the mid¬ 
line deprived the urethra and bladder of their natural support, and thus 
exposed them to serious injury during the delivery of the child. To 
overcome these difficulties, he proposed that the incision be made through 
the pubic bone itself, as he held that the bone wound would heal more 
rapidly and be less liable to infection, while its lateral position would 
avoid interference with the attachments of the urethra and bladder, and 
thus reduce to a minimum the possibility of their injury. In order to 
sever the bone he invented the flexible wire saw, which is known by 
his name. 

Gigli did not perform the operation until April, 1902, but his sugges¬ 
tion was put into practice by Bonard, of Lugano, in 1897, who was 
followed by Calderini and Van der Yelde in 1899 and 1901, respectively. 
Following the report of the latter, the operation was rapidly taken up 
and modified, so that three methods are now available. 

Technic. —Originally, the anterior surface of the bone was exposed 
by an oblique incision, beginning slightly above the inner margin of the 
pubic spine and extending to the middle of the outer part of the labium 
majus. Then by means of a pair of artery forceps the saw was adjusted 
to the posterior surface of the bone, which was then severed. In 1904 
Doderlein modified the operation and, and instead of a large open wound, 
made a small incision, just large enough to admit a finger, parallel to and 
somewhat above the pubic bone. After separating the periosteum, a 
curved instrument, somewhat like a large aneurism needle, was passed 
behind the bone and pushed through the labium majus. The saw was 
then fastened to the protection at the lower end of the instrument, and 
brought into position by withdrawing it. In 1906 Stoeckel and Kan- 
negiesser reported that their respective chiefs, Bumm and Leopold, had 
performed the operation extirely subcutaneously. For this purpose the 
instrument was thrust through the upper end of the labium majus, 
and, under the guidance of a finger in the vagina, carried up along the 
posterior surface of the pubic bone and brought out through the skin 
above its upper margin, between the pubic spine and the symphysis pubis, 
the saw being adjusted by withdrawing the instrument from above down¬ 
ward. 

Up to April, 1915, my assistants or myself have performed 43 consec¬ 
utive successful pubiotomies upon 40 patients, three women having been 
■ operated upon twice. As Doderleiids method was employed in all but 
the first case, and has proved most satisfactory, I shall describe its technic 
in some detail. 

After emptying the bladder and rectum and shaving the lower abdo¬ 
men and pubic region, the patient is brought to the edge of the table, and 
prepared for operation in the usual manner. The legs are held by 
assistants. An incision extending 2% centimeters inward from the pubic 
spine is then made just above the upper margin of the public bone, and 
the tissues cut through down to it. After incising the periosteum, a 
finger is passed into the wound and separates the tissues from the pos¬ 
terior surface of the bone. Then a Doderlein needle is carried down 
along the posterior surface of the bone, and when its inferior 




520 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


margin is reached the handle of the needle is rotated in such a man¬ 
ner that its tip is felt through the upper and outer part of the 
labium majus. A small incision is made over the projection, through 
which the tip of the instrument is pushed. To it one end of the saw 
it attached, and is drawn into position as the instrument is withdrawn 

through the upper wound. The 
handles are then attached to the saw 
and a few movements suffice to sever 
the bone. Care should be taken that 
the bone is severed in the desired 
direction, and that the movements 
are continued until the saw moves 
freely beneath the skin. 

In many cases the ends of the 
bone gape for 2 or 3 centimeters as 
soon as the section is complete; but, 
if all the ligamentary structures 
have not been divided, this does not 
occur until traction is made upon 
the child. Upon withdrawing the 
saw, blood gushes freely from both 
wounds, but in all of my cases the 
hemorrhage was readily controlled 
by firm pressure with gauze sponges. 
As soon as it is checked, the child 
should be delivered by forceps or 
version, as is most convenient, as 
I can see no advantage in waiting 
for its spontaneous expulsion, as 
recommended by certain German 
writers. As traction is made, the 
ends of bone will gape more 
widely, but a separation of more than 5 or 6 centimeters should be 
avoided by having the assistants make firm pressure upon the thighs. 
While waiting for separation of the placenta, a small gauze drain should 
be brought through the opening in the labium majus, and the upper 
wound sutured. 

After labor the patient is cleaned up, a sterile dressing is applied 
over the upper wound, and a long strip of adhesive plaster six inches wide 
is then passed around the entire body so as to make firm and equal pres¬ 
sure over the trochanters. This is not at all essential, as many German 
operators do not attempt to immobilize the pelvis. The patient is then 
put to bed, and, for convenience in handling, placed upon a Bradford 
frame, upon which she begins to move freely on the second or third 
day. She is not catheterized unless necessary, and is kept in bed for 
fourteen days, but is allowed to sit up as soon as she desires. She is 
encouraged to try to walk on the second day after getting up. The power 
of locomotion soon returns, and all of my patients have felt able to leave 
the hospital before the end of the fourth week. 





PUBIOTOMY 


521 


I have had no experience with the purely subcutaneous operation, 
but Roemer states that it is followed by injuries to the bladder twice as 
frequently as when Doderlein’s technic is employed, so that it would 
seem that the possibility of injuring the bladder is somewhat lessened 
by separating the tissues posterior to the bone with the fingers. 

Healing of the bone wound usually occurs by fibrous union, which was 
noted after all of our operations. This, however, has no effect upon 
locomotion, as all of my patients, upon reexamination months or years 
later, stated that they were able to walk as well and work as hard as 
previously. Moreover, the occurrence of fibrous union should be regarded 
as a favorable outcome, for the reason that it sometimes leads to a 
definite enlargement of the pelvic diameters, which may be still further 
accentuated in a subsequent pregnancy by the softening and relaxation 



Fig. 440 . —Showing Position of Patient and Gigli Saw. 


incident to the increased hyperemia attending that condition. In 1915 I 
reported that 20 of my pubiotomy patients had subsequently given birth 
to 30 children. Ten of them had 12 spontaneous labors at term; in 
the others operative interference was again necessary. It therefore 
appeared that there is an almost even chance of the pelvis becoming 
definitely enlarged as the result of pubiotomy, and careful pelvic men¬ 
suration showed the correctness of the supposition; as the conjugate 
vera was found to be lengthened in 6 and the transverse diameter of the 
outlet in 11 instances. In the former, the increase was but slight, and 
only in two cases did it amount to as much as 1 centimeter; whereas 
in the latter the increase was considerable, varying between 1 and 3 
centimeters, and averaging 1.8 centimeters. These observations indicate 
that considerable permanent enlargement of the pelvis is not to be 
expected when the contraction involves the superior-strait; whereas, it 
does occur in funnel pelves, when it is often sufficient to convert the con- 







522 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


tracted outlet into a normal one, and thus permit subsequent spontaneous 
labors. 

Prognosis. Maier, in 1907, and Schlafli, in 1909, collected 2G7 and 
700 operations from the literature with a mortality of 5.6 and 4.82 per 
cent., respectively. I do not consider that their figures correctly repre¬ 
sent the real dangers of the operation, as Schlafli’s statistics are based 
upon the results of 142 operators, many of whom had little experience, 
and naturally could not lie expected to obtain the best results. On the 
other hand, Doderlein states that in 321 pubiotomies performed in 7 
German clinics up to 1910, the mortality was 1.8 per cent., and my own 
experience has indicated that it should not be greater. Such results are 
comparable to those following early conservative cesarean section, and 
are far superior to those obtained when it is performed after a test of 
the second stage of labor. 

Usually the hemorrhage, which may be quite profuse, is venous in 
character, and is readily controlled by pressure; but occasionally aberrant 
branches of the internal pudic artery may be cut, when it may become 
necessary to lay the entire wound open to ligate the bleeding vessel. 
Very exceptionally, even this is not possible, and one of Rosthorirs 
patients died from uncontrollable hemorrhage. 

Moreover, deep vaginal tears frequently occur during the extraction of 
the child, and require immediate repair; while less often the bladder 
or urethra is injured, either by being perforated by the sharp ends of the 
bone, or as the result of traction. If proper care is taken in dilating 
the birth canal with hand before beginning the operation, by making 
horizontal instead of upward traction when delivering the head, and by 
avoiding undue violence, the occurrence of such accidents can be mini¬ 
mized. In only one of my cases was the bladder injured; in a number 
the vagina was torn, but in each instance satisfactory healing resulted 
after primary repair. Strange to say, the perineum is but rarely torn. 

Convalescence in general is very satisfactory, and the patients com¬ 
plain of but little pain or discomfort. In nearly one half of the cases the 
puerperium is slightly febrile, but only one of my patients was seriously 
ill. In many instances there is considerable edema about the vulva and 
occasionally hematomata of considerable size develop. Moreover, several 
writers believe that the operation considerably increases the liability to 
femoral phlebitis. 

Indications.—Pubiotomy is performed solely in the interests of the 
child, and is contra-indicated when it is dead or in poor condition, or 
when the conjugata vera measures 7 centimeters or less. Furthermore, 
even in pelves above this limit, it is never indicated as a primary opera¬ 
tion. For this reason, it should not be performed in patients presenting 
disproportion between the size of the head and the pelvis, who are seen 
before the onset of labor or within a few hours thereafter, as in them 
classical cesarean section is the operation of choice. On the other hand, 
if the patient is not seen until late in labor, pubiotomy will give better 
results. 

In my experience, the chief indication for the operation is presented 
by patients in whom the disproportion appears to be so slight that spon- 






PUBIOTOMY 


523 


taneous delivery is anticipated, but in whom the test of several hours of 
second stage pains demonstrates that the head cannot be forced through 
the superior strait. In such circumstances the mortality following 
classical cesarean section is in the neighborhood of 10 per cent., while 
that of pubiotomy is 1 per cent., and consequently, there should be no 
difficulty in determining which operation is indicated. If, however, the 
innocuousness of extraperitoneal cesarean section can be demonstrated 
under these conditions, the field of usefulness of pubiotomy will be still 
further restricted. Bill of Cleveland took an identical position in 1923, 
and holds that pubiotomy has this restricted, but definite, field of useful¬ 
ness. 

In view of the permanent widening of the pelvic outlet to which 
reference has already been made, I consider that the ideal indication for 
pubiotomy is afforded by pronounced grades of funnel pelvis; as in them 
the operation will not only permit the delivery of the child, but in all 
probability will lead to such permanent enlargement of the outlet that 
spontaneous labor will be possible in the future. On this account, pubi¬ 
otomy is preferable to elective cesarean section, except in really elderly 
primiparae, in whom no chances can be taken with the prospects of secur¬ 
ing a living child. I cannot, however, endorse the suggestion of Jellett, 
who proposes that pubiotomy be done in non-pregnant women as a 
prophylactic measure, in the expectation that it will radically cure the 
pelvic deformity. 

I hold that pubiotomy will still further narrow the field for the induc¬ 
tion of premature labor, and practically do away with the use of high 
forceps, version, or craniotomy in moderate degrees of contracted pelvis 
when the mother or child is in good condition. Pubiotomy may also be 
indicated in face presentations when the chin has rotated into the hollow 
of the sacrum. 

In certain cases of breech or transverse presentation associated with 
moderate degrees of pelvic contraction, laying the Gigli saw prophylac- 
tically before beginning extraction adds greatly to one’s equanimity, as 
it enables one to saw through the pubic bone as soon as serious resistance 
develops, and thus save the life of the child which otherwise would be 
lost. In such cases, pubiotomy is usually not necessary, but the knowl¬ 
edge that it can be resorted to immediately adds greatly to the operator’s 
feeling of security. 

I do not believe that pubiotomy should be undertaken when signs 
of infection are present, as the interests of the mother will be better 
served by craniotomy or cesarean section followed by the removal of 
the uterus. Likewise, I feel that the employment of pubiotomy should 
be limited to well-equipped hospitals or to the practice of experts, since 
several well-trained assistants are necessary to its proper performance, 
and, moreover, serious complications may occur at any time, which will 
seriously tax the resources of even a competent surgeon. 


524 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


LITERATURE 

Ahlfeld. Lehrbuch der Geburtsliiilfe, II. Aufl., 1898, 547. 

Bar. De 1 ’operation cesarienne conservative, etc. L’obstetrique, 1899, iv, 193- 
230. 

Legons de pathologie obstetricale. Paris, 1900. 

Baudelocque, A. Nouveau procede pour pratiquer 1’operation cesarienne. These 
de Paris, 1823. 

Baudelocque, J. L. De la section du pubis. L’art des accouchements, nouv. ed., 
1789, ii, 461-561. 

Bauhin. ‘ yarepoToiJLOTOKia . F.r. Rousseti, etc. Basil, 1588. 

Beck. The Two-flap Cesarean Section. Surg. Gyn. and Obst., 1921, xxxiii, 
290-295. 

Bill. Should Pubiotomy Be Recognized as a Justifiable Operation in Obstetrics. 
Am. Jour. Obst. and Gyn., 1923, v, 258-261. 

Birnbaum. 5 Kaiserschnitte bei einer Person. Arehiv f. Gyn., 1885, xxv, 422. 

Bischoff. Die totale Exstirpation des schwangeren und carcinomatosen Uterus 
Correspondenzbl. f. Schweizer Aerzte, 1880, Nr. 6. 

Braun-Fernwald. Ueber den in den letzten 10 Jahren ausgefiihrten Sectioncs 
Caesareae. Arehiv f. Gyn., 1899, lix, 320-404. 

Brodhead. Rupture of the Uterus Through the Caesarean Cicatrix. Am. Jour. 
Obst., 1908, lvii, 650-666. 

Budin. Tarnier et Budin, Traite de l’art des accouchements, 1901, iv, 495. 

Budin et Demelin. Symphyseotomie. Tarnier et Budin, Traite de l’art des 
accouchements, 1901, iv, 456-489. 

Caruso. Die neuesten Ergebnisse des conservativen Kaiserschnittes mit Uterus- 
naht. Arehiv f. Gyn., 1888, xxxiii, 211-269. 

Chrobak. Quoted by Braun-Fernwald. 

Davis. A. B. A Report of all Abdominal Cesarean Operations Performed in 
the Service of the Lying-in Hospital. Am. J. Obst., 1915, lxxi, 116-132. 

De Lee-Cornell. Low Cervical Cesarean Section. Jour. Am. Med. Assoc., 1922, 
lxxix, 109-112. 

Doderlein. Ueber alte u. neus beckenerweiternde Operationen. Arehiv. f. Gvn., 
1904, lxxii, 275-293. 

Ueber extra-peritonealen Kaiserschnitt u. Hebosteotomie. Monatsschr. f. Geb. 
u. Gyn., 1911, xxxiii, 1-21. 

Farabeuf. Sur la symphyseotomie. Annales de gyn. et d’obst., 1894, xli, 407- 
431. 

Felkin. Quoted by Ploss. Das Weib in der Natur- und Volkerkunde, IY. An* 3 ., 
1895, ii, 297. 

Fraenkel, L. Experimente zur Herbeifiihrung der Unwegsamkeit der Eileiter. 
Arehiv f. Gyn., 1899, lviii, 374-410. 

Frank. Ueber den subkutanen Symphysenschnitt, etc. Monatsschr. f. Geb. u. 
Gyn., 1910, xxxii, 680-692. 

Fritsch. Ein neuer Schnitt bei der Sectio Caesarea. Zentralbl. f. Gyn, 1897, xxi, 
561-565. 

Fruhinsholz. De 1’operation cesarienne repete chez la meme femme. Annales 
de gyn. et d’obst., 1906, iii, 135-147. 

Gigli. Taglio lateralizzato del pube, sua vantaggi, sua tecnica. Ann, di os. e gin., 
1894, No. 10. 

Lateralschnitt des Beckens. Zentralbl. f. Gyn., 1904, xxviii, 281-299. 

Halbertsma. Eclampsia gravidarum eine neus Indikationsstellung fur die 
Sectio Caesarea. Zentralbl. f. Gvn., 1889, xiii, 901. 


LITERATURE 


525 


Harris. Remarks on the Caesarean Operation. Amer. Jour. Obst., 1879, xi, 620* 
626. 

Cattle-horn Lacerations of the Abdomen and Uterus in Pregnant Women. Amer. 

Jour. Obst., 1887, xx, 673-685, and 1033. 

Results of the Porro Caesarean Operation in All Countries. British Med. Jour., 
1890, i, 68. 

The Remarkable Results of Antiseptic Symphyseotomy. Trans. Amer. Gyn. Hoc., 

1892, xvii, 98-126. 

The Porro Caesarean Section Tested by a Trial of Sixteen Years, etc. N. Y. 
Jour, of Gyn. and Obst., 1893, iii, 273-283. 

Harris. A Study of the Results Obtained in 64 Cesarean Sections Terminated 
by Supravaginal Hysterectomy. Bull. Johns Hopkins Hosp., 1922, xxxiii, 
318-321. 

Holland. The Results of a Collective Investigation into Caesarean Section Per¬ 
formed in Great Britain from the Year 1911 to 1920 Inclusive. Jour. 
Obst. and Gyn. Br. Emp., 1921, xxviii, 358-446. 

Rupture of the Cesarean Scar in Subsequent Pregnancy and Labor. Proc. 
Royal Med. Soc., 1920, xiv (Gyn. and Obst.), 22-124. 

Holzapfel. Kaiserschnitt bei Mastdarmkrebs. Beitrage zur Geb. u. Gyn., 1899, 
ii, 59-77. 

Jaschke. Megakolon als Geburtshinderniss. Zentralbl. f. Gyn., 1915, 747-750. 
Jellett. The Radical Cure of Pelvic Deformity. Surg. Gyn. and Obst., 1919, 
xxix, 117-125. 

Jewett. A Case of Symphyseotomy. Brooklyn Med. Jour., 1892, vi, 790-792. 
Kannegeisser. Beitrag zur Hebotomie auf Grund von 21 Falle. Archiv f. Gyn., 
1906, lxxviii, 52-105. 

Kronig. Zur Behandlung der Placenta praevia. Beitrage z. Geb. u. Gyn., 1909, 
xiii, 477-479. 

Transperitonealer, cervicaler Kaiserschnitt. Kronig-Doederlein, Operative 

Gynakologie, III. Auf., 1912, 879-886. 

Kustner. Kommen wir mit dem tiefen transperitonealen Kaiserschnitt aus, 
etc. Monatsschr. f. Geb. u. Gyn., 1920, liii, 13-56. 

Latzo. Ueber den extra-peritonealen Kaiserschnitt. Zentralbl. f. Gyn., 1909, 
275-283. 

Lebas. Jour de Med. et de Chirurgie, 1770, xxxiv (supplement). 

Leopold. Welche Stellung nimmt die klassiche Sectio caesarea, etc. Archiv f. 
Gyn., 1910, xci, 453-460. 

Litzmann. Kaiserschnitt mit temporarer Ligatur des Cervix. Zentralbl. f. Gyn., 
1879, iii, 289-295. 

Maier. Der gegenwartige Stand der Hebotomie. D. I., Tubingen, 1907. 
Morisani. De la symphyseotomie. Annales de gyn. et d’obst., 1881, xvi, 444-445. 
Neugebauer. Ueber die Rehabilitation der Schamfugentrennung, etc. Leipzig, 

1893. 

Physick. See Dewees ’ Compendious System of Midwifery. Phila., 1824, p. 580. 
Pinard. De la symphysetomie. Annales de gyn. et d’obst., 1892, xxxvii, 81-94. 
T ndication de Uoperation eesarienne consideree en rapport avee celle de la sym¬ 
physeotomie, etc. Annales de gyn. et d’obst., 1899, Iii, 81-117. 

Porro. Della amputazione utero-ovarica, etc. Milan, 1876. 

Report of Committee on Maternal and Infant Welfare of the Massachusetts 
Medical Society. Boston Med. and Surg. Jour., 1923, clxxxviii, 288-290. 
Reynolds. Constitutional Ill Equipment of the Patient as a Factor in Determin¬ 
ing the Performance of Caesarean Section. J. Am. Med. Assn., 1907, xlix, 
1329-1333. 


526 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 


Reynolds. The Superiority of Primary over Secondary Caesarean Section. 

Trans. Am. Gyn. Soc., 1907, xxxii, 116-118. 

Rousset. Traite nouveau de 1 ’hvsterotomotokie on 1 ’enfantement cesarien. Paris, 
1581. 

Routh. On Caesarean Section in the United Kingdom. J. Obst. and Gyn. Brit. 
Emp., 1911, xix, 1-233. 

Sanger. Der Kaiserschnitt bei Uterusmyomen, etc. Leipzig, 1882. 

Schlafli. 700 Hebosteotomien. Zeitschr. f. Geb. u. Gyn., 1909, lxiv, 85-135. 
Sellheim. Der extra-peritoneale Uterusschnitt. Zentralbl. f. Gyn., 1908, 133- 
142. 

Sigault. Discours sur les avantages de la section symphyse dans les ac- 

couchemens, etc., Paris, 1779. 

Spinelli. Les resultats de la symphyseotomie, etc. Annales de gyn. et d’obst., 
1892, xxxvii, 2-15. 

Stoeckel. Symphyseotomie oder Pubiotomie. Zentralbl. f. Gvn., 1906, xxx, 78-84. 
Storer. Extirpation of the Puerperal Uterus by Abdominal Section. Jour. Gyn. 
Soc. of Boston, 1861, i, 223. 

Thomas. Gastro-elytrotomy: A Substitute for the Caesarean Section. Amer. Jour. 
Obst., 1871, iii, 125-139. 

Trautmann. See Siebold, Versuch einer Geschicht der Geburtshiilfe, 1845, ii, 108- 

111 . 

Van de Yelde. Die Hebotomie. Zentralbl. f. Gyn., 1902, xxvi, 969-976. 
Williams. Pelvic Indications for the Performance of Caesarean Section. Trans. 
Amer. Gyn. Soc., 1901, xxvi, 260-276. 

Is Pubiotomy a Justifiable Operation? Am. J. Obst., 1910, lxi, No. 5. 

The Effect of Pubiotomy upon the Course of Subsequent Laburs. Am. J. Obst., 
1915, lxxii, 1-25. 

The Abuse of Caesarean Section. Surg. Gyn. and Obst., 1917, xxv, 194-201. 

A Critical Analysis of Twenty-one Years’ Experience with Caesarean Section. 
Johns Hopkins Hosp. Bulletin, 1921, xxxii, 173-184. 

Zweifel. Die subcutane Symphyseotomie. Zentralbl. f. Gyn., 1906, 737-742. 


CHAPTER XXIII 


DESTRUCTIVE OPERATIONS 

CRANIOTOMY 

Under this heading are included all operations which bring about a 
decrease in the size of the foetal head, with a view to rendering its 
delivery easier. 

Prior to the introduction of podalic version and forceps, artificial 
delivery could be effected only by means of craniotomy or embryotomy, 
one or other of which was resorted to in nearly every case of difficult 
labor. Accordingly, in former times, the perforator, sharp hook, and 
crotchet were the most important instruments in the obstetrician’s arma¬ 
mentarium. Increased dexterity in the employment of forceps and 
version, however, brought about a rapid change, and now, as the result 
of the great decrease in the mortality from cesarean section, many 
obstetricians hold that craniotomy upon the living child is not justifiable 
in any circumstances. 

Indications. —Craniotomy is positively contra-indicated when the 
conjugata vera measures less than 5.5 centimeters, since in such cases 
the extraction of the child, even after the skull has been crushed, is at¬ 
tended by a greater maternal mortality than cesarean section late in 
labor. On the other hand, in pelves above this limit, while craniotomy 
may be indicated whenever the delivery of a mutilated child is the 
most conservative procedure, so far as the safety of the mother is con¬ 
cerned, its employment should be restricted to the greatest possible 
extent. 

The indications for its performance vary markedly. When the child 
is dead craniotomy is always indicated, unless the disproportion between 
the head and the pelvis is so slight that delivery by forceps or version 
can be accomplished without detriment to the mother. Esthetic con¬ 
siderations should never deter the operator from resorting to it. On 
the other hand, if the child is alive, the operation is justifiable only 
in very exceptional cases; indeed, many authorities go so far as to 
hold that, in view of the satisfactory results obtained from pubiotomy 
and cesarean section, it should never be performed. This, however, 
must be looked upon as too radical a view; for, although it must ever 
be the duty of the obstetrician to do his best to save the life of both 
mother and child, it is nevertheless conceivable that conditions may arise 
under which craniotomy upon the living child may not only be perfectly 
justifiable, but even imperatively demanded. 

Generally speaking, craniotomy should not be performed upon the 

527 


528 


DESTRUCTIVE OPERATIONS 


living child if the mother is in good condition, amid suitable sur¬ 
roundings, and in the hands of a competent operator. In such circum¬ 
stances, if the obstacle to labor be due to a contracted pelvis or a large 
child, cesarean section or, in certain cases, pubiotomy is preferable, 
inasmuch as the slightly increased risk to the mother is more than 
compensated for by the rescue of her offspring. On the other hand, if 
the woman is not seen until she has been in the second stage of labor 
for a considerable time, and is already infected, classical or extra- 
peritoneal cesarean section, as well as pubiotomy, is clearly contra-indi¬ 
cated. In such circumstances in primiparous women the child should 
be sacrificed in the interests of the mother, as the only safe alternative 
consists in cesarean section followed by hysterectomy, which inevitably 
entails complete abolition of the reproductive function. Again, if the 
child is in poor condition, as shown by a too rapid or too slow heart¬ 
beat, or by the passage of considerable quantities of meconium with 
a vertex presentation, its life is already in such peril that, against that 
of the mother, it is no longer entitled to serious consideration. 

Moreover, in country districts, where the physician is unable to 
summon sufficient assistance, and is without the necessary appliances for 
an aseptic operation, cesarean section or pubiotomy should not be under¬ 
taken, and craniotomy becomes the operation of choice. But even under 
these adverse conditions, the destructive operation should be deferred 
as long as possible, and should not be resorted to until delivery becomes 
imperative in the interests of the mother, and then only after the failure 
of tentative attempts at forceps delivery. If, however, the patient hould 
again become pregnant, she should he sent to a city where expert treat¬ 
ment can be obtained, as I consider that a physician who repeatedly 
performs craniotomy upon the same patient is little better than a pro¬ 
fessional abortionist. 

Hydrocephalus affords a positive indication for craniotomy, which 
should he performed as soon as the cervix is completely dilated. In 
many instances extraction will not be necessary, as the mere evacuation 
of the fluid may he followed by the spontaneous extrusion of the child. 
In this condition a destructive operation is the more readily undertaken, 
as even a successful cesarean section will only give us a child that is 
doomed to die sliortlv or remain an idiot. 

When insuperable obstacles are encountered during the extraction of 
the after-coming head, craniotomy is a justifiable procedure, since the 
child is already dead, or dies within a few minutes after the nature of 
the obstacle has been recognized, and before preparations can be made 
for its delivery by pubiotomy. 

Craniotomy should not be performed upon the mature child until 
the external os has become completely dilated, as the imperfectly opened 
canal may offer a serious obstacle to its extraction. 

Operative Technic.—The patient should be placed in the lithotomy 
position, and prepared as for other obstetrical operations. Craniotomy 
usually includes two steps: First, the perforation of the head and 
evacuation of its contents; and, secondly, the extraction of the mutilated 
child. 


CRANIOTOMY 


529 


Numerous instruments have been devised for perforating the head, 
the most suitable of which are Smellie’s scissors or Blot’s perforator' 
Braun’s trepan would serve the purpose admirably, but is not to be 
recommended on account of the difficulty with which it is kept clean. 

If the head is engaged and firmly fixed, perforation is accomplished 
with but little difficulty. With two fingers the large or small fontanel, 
as may be most convenient, is located, and the perforator plunged 



through it. The opening is then enlarged and the instrument briskly 
moved about within the skull so as to destroy the central ganglia, and 
to disintegrate the brain to such an extent that it can be washed out 
with a douche of sterile water. 

If, however, the head is movable above the superior strait, it must 
be firmly fixed by means of pressure exerted by an assistant through 
the abdominal walls. To avoid wounding the maternal soft parts, the 


Fig. 442. —Method of Perforating Head (American Text-Book). 

perforation should he made through the portion of the head lying in 
the neighborhood of the symphysis pubis; for, should the instrument 
slip from this position, it is less liable to inflict serious injury than if 
it were near the sacrum. In face presentations perforation should be 
effected through the frontal suture. 

To pierce the after-coming head, the body of the child should be 
depressed, and the instrument carried into the skull in the neighborhood 
of the temporal suture. If, as occasionally happens, this point cannot 
be reached, the body of the child should be carried up over the abdomen 















530 


DESTRUCTIVE OPERATIONS 


of the mother, and perforation effected through the mouth and base 
of the skull. When a hydrocephalic child presents by the breech, and 
the head is arrested at the pelvic brim, the fluid contents of the skull 
may be evacuated by cutting through the arch of one of the cervical 



vertebrae, after which a metallic catheter is passed through the opening 
and carried along the vertebral canal into the skull. 

After the brain has been washed out, the collapsed head may be 
expelled by the uterine contractions alone, or may be extracted by means 

of the forceps or a finger 
introduced through the per¬ 
foration opening. But even 
in moderate degrees of pel¬ 
vic contraction it is usually 
advisable to make use of a 
special instrument for 
grasping and crushing the 
base of the skull. The 
cranioclast, invented ' by 

Simpson and modified by 
Carl Braun, serves the pur¬ 
pose most satisfactorily. Its 
solid blade is introduced 
through the perforation 
until its free end impinges 
upon the base of the skull, 
while the fenestrated blade 
is applied over the face or 
lower portion of the occiput. 
The vise at the end of the 
instrument is then tight¬ 
ened, and as a result not 
only is the base of the skull 
more or less compressed, 
but at the same time a firm 
hold is obtained for the extraction that is to follow. 

Although the vault of the cranium collapses after craniotomv and 
the washing out of its contents, the base of the skull still remains 
unchanged and, as the bimastoid diameter measures between 7 and 7.5 



Fig. 444.- 


-Head Crushed by Cranioclast 
(Simpson). 























CRANIOTOMY 


531 


cm., it is obvious that delivery cannot be effected through a pelvis 
presenting smaller measurements until the base of the skull has like¬ 
wise been crushed. For this purpose many instruments have been 



devised, and formerly the cephalotribe, invented by Baudelocque the 
younger, was extensively employed. This is essentially a very heavy 
forceps, whose blades come closely together and forcibly compress the 
head, when the vise at the ends of the handles is tightened. The in- 



Fig. 146a,—T arnier’s Basotribe, Disarticulated. 


strument has been subjected to many modifications, the best being those 
of Tarnier and Braxton Hicks. At the same time it labors under the 
disadvantage that it aims to accomplish two purposes— i. e., crushing 
and extracting the head; and, unfortunately, whenever it is so con- 



Fig. 146, b . —Tarnier’s Basotribe. 


structed as to be an efficient crusher it is a poor tractor, and vice versa. 
For these reasons the cephalotribe, as such, is but little used. 

Tarnier, in 1883, invented the basiotribe, a three-bladed instrument 


























532 DESTRUCTIVE OPERATIONS 


which combines in one the advantages of the perforator, cranioclast, and 
cephalotribe. One blade is spear-pointed, and after serving as a per¬ 
forator is forced into the base of the skull. 
The second blade is then introduced over 
the occiput and the third over the face of 
the child. All three are articulated, and the 
vise at the handles is screwed down, with 
the result that the base of the skull is frac¬ 
tured in many directions, and the head is 
compressed into an elongated and shapeless 
mass. This is a most efficient instrument, 
and has been particularly recommended by 
Pinard and Bar. 

Sir A. R. Simpson, of Edinburgh, devised 
an instrument known as the basilyst-tractor, 
which likewise consists of three blades. The 
tips of two of them come together and form 
a screwlike instrument. This first perforates 
the skull, and by a rotatory motion is then 
worked into the base, which is fractured in 
many directions by separating the two 
blades by pressure upon the handles. After 
this the third blade is introduced over the 
face or occiput and screwed tightly in place, 
thus converting the instrument into a typical 
cranioclast (Figs. 448 and 449). The 
basilyst-tractor gives very satisfactory results, 
and according to its inventor will compress 
the base of the skull into a mass 3.5 centi¬ 
meters in diameter. 

When perforating a hydrocephalic child, 
it is important to remember that the brain 
is spread out over the interior of the skull as a layer of tissue which 
may be only a few millimeters thick. When this is perforated, the 


Fig. 447. —Effect of Basio- 
tribe. 


fluid filling the dilated ventricles of the brain escapes and the skull 
collapses, after which delivery is readily effected. Occasionally per- 


Fig. 448. —Simpson’s Basilyst, Disarticulated. 

















EMBRYOTOMY 


533 


foiation does not result in the death of the child, which will cry after 
its hiith. In order to guard against this most distressing occurrence, 
the obstetrician should not he content with merely perforating the 
skull at one point, but should carry the instrument back to the base 
of the biain and stir it around so as to destroy effectually the upper 
portion of the medulla. Pernice having reported the case of an infant 
who survived craniotomy and grew up an idiot. 

Prognosis. In moderate degrees of pelvic contraction, craniotomy, if 
properly performed in uninfected women, is almost devoid of danger. 
On the other hand, when the conjugata vera measures 5.5 centimeters 
or less, the mortality becomes considerable. Moreover, it must be re- 
membered that if the operation be deferred until infection has occurred, 
and the patient has become profoundly exhausted, its mortality approxi¬ 
mates that of late cesarean section. 


EMBRYOTOMY 



Fig. 449. —Simpson’s Basilist, Articulated. 


In embryotomy the viscera are removed through an opening in the 
thorax or abdomen of the child, or the head is severed from the body. 
The former operation is known as evisceration, the latter as decapitation. 

At present evisceration is rarely employed, though 
it occasionally becomes necessary in order to effect 
the delivery of certain monstrosities, or children 


suffering from unusual enlargement of the thoracic or abdominal 

cavities resulting from tumor formation. It may likewise become 

necessary in rare cases of transverse presentation, when the thorax 

or abdomen of the child lies over the superior strait and the neck 

is not accessible. In such circumstances an opening is made by 

scissors through the thoracic or abdominal wall, as the case may be, 

sufficiently large to admit two fingers, with which the viscera are torn 

loose from their attachments and slowlv extracted. 

%/ 

Decapitation is much more frequently employed, and is indicated 
more particularly in neglected transverse presentations. As a rule, when 
seen early, such cases can be readily delivered by version and extraction; 
but when the condition has been overlooked, and assistance is not called 
for until one shoulder has become firmly impacted in the pelvic canal, 
the lower uterine segment may have become so stretched as to make an 
attempt at version practically synonymous with rupture of the uterus. 
Under such circumstances the child can be delivered only by decapita¬ 
tion or cesarean section. The former is the operation of choice in 













534 


DESTRUCTIVE OPERATIONS 




neglected cases, and should always be chosen if the child is dead. It 
can readily be accomplished by means of Braun’s blunt hook or of 
John Ramsbotham’s sickle knife, which is extensively used in Eng¬ 
land. 

Classical cesarean section is always associated with a high mortality 

in such circumstances, as 
the patient has usually 
been long in labor and is 
exposed to serious danger 

Fig. 450. —Braun’s Blunt Hook. of infection. If, however, 

the child is in good con¬ 
dition, as indicated by strong foetal heart sounds, and the mother is 
earnestly desirous of offspring, cesarean section followed by supra¬ 
vaginal hysterectomy may be undertaken if the patient is a mul¬ 

tipara; whereas it should not be considered in the case of a primiparous 
woman, since the loss of a child with somewhat dubious chances of 
life should be regarded as a lesser evil than permanent sterilization. 

Fortunately, in neglected shoulder 
presentations, decapitation is usually 
materially facilitated by the prolapse 
into the vagina of one arm. This 
having been seized and brought 

through the vulva, firm traction 

should be exerted upon it so as to 
put the neck on the stretch as much 
as possible. The index finger of one 
hand is then passed over the neck 
and used as a guide in applying 
Braun’s hook as accurately as pos¬ 
sible. When in position, the tip of 
the instrument is covered by the finger 
so as to avoid wounding the maternal 
soft parts. All being in readiness, 
strong traction is now made upon the 
handle of the instrument, which at the 
same time is rotated from side to side, 
somewhat as a key in a lock, by which 
the cervical vertebrae are disarticu¬ 
lated, and on continuation of the mo¬ 
tion the neck is readily severed from 
the body. If any resistance is offered 
by the skin, it may be cut with scis¬ 
sors. After decapitation the body is 
extracted by traction upon the arm; 
or, if that be not available, by version. 

The head can frequently be expressed from the uterus by maneuvers 
similar to those employed for the delivery of the placenta, but if these 
prove unsuccessful a finger is inserted into the mouth of the child, 
after which, as a rule, extraction is readily effected by traction up. n the 


Fig. 451. —Decapitation with Braun’s 
Blunt Hook (American Text-Book). 











LITERATURE 


535 


lower jaw. If this is not effectual delivery can be accomplished by 
means of a cephalotribe or after perforation. 

Zweifel believes that decapitation can be rendered easier by the use 
of the trachelorhekter, which consists essentially of a double Braun's 
hook. So far as my own experience goes, I see no necessity for the 
new instrument, as I have always been able to effect decapitation by 
means of Brauns hook. Again, if the latter be not available, the 



Fig. 452. 



Fig. 453. 


Figs. 452, 453.—Showing Mode of Action of Blunt Hook (American Text-Book). 


operation may be performed by means of a pair of long curved scissors, 
similar to the embryotomy scissors of Hodge. 

Occasionally, in head presentations, the excessive size of the shoulders 
may prove a serious obstacle to labor. In such cases cleidotomy renders 
excellent service. In this operation a pair of long curved scissors are 
introduced under the guidance of the hand and cut through the clavicles 
on either side, after which the shoulder girdle collapses and delivery 
is readily effected. According to Ballantyne, cleidotomy was first pro¬ 
posed by Herbert R. Spencer, instead of Yon Herff as is usually stated. 


LITERATURE 

Bar. Embryotomie cephalique. Paris, 1889. 

Baudelocque. Nouveau moyen pour delivrer les femmes contrefaites et en travail. 
Paris, 1829. 

Braun. Ueber das technische Verfahren bei vernachlassigten Querlagen, etc. 
Wiener med. Wochnschr., 1861, Nr. 45. 

Pernice. Ueber einen giinstig verlaufenen Fall von Perforation, etc. Zentralbl. 
f. Gyn., 1900, xxiv, 918-921. 

Pinard. Le basiotribe Tarnier. Annales de gyn. et d’obst., 1884, xxii, 321-341 
and 406-442. 

Du soi-disant foeticide therapeutique. Annales de gyn. et d’obst., 1900, liii, 
1-18. 








536 


DESTRUCTIVE OPERATIONS 


Simpson, A. R. Delivery by Basilysis. Scottish Med. and Surg. Jour., 1900 
(May). 

Simpson, J. Y. Cranioclast. Med. News and Gaz., 1860, vol. i. 

Tarnier. Le basiotribe. Acad, de med. de Paris, 1883, December 11. Annalcs de 
gyn. et d’obst., 1884, xxi, 74-77. 

Von Herff. Die Zertriimmerung des Schultergiirtels (Kleideotomie). Archiv f. 
Gyn., 1895, liii, 542-546. 

Zweifel. Ueber die Dekapitation, etc. Zentralbl. f. Gvn., 1895, xix, 521-539. 













CHAPTER XXIV 


OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY 

In this chapter will be considered a number of procedures usually 
designated as minor operations, which may become necessary during 
pregnancy, labor, or the puerperium. 

The Douche.—We distinguish between vaginal and uterine douches, 
according as a considerable quantity of fluid is injected into the vaginal 
canal alone or directly into the uterine cavity. 

Vaginal Douche .—Following the introduction of antiseptic methods 
into obstetrics, the use of an antiseptic, prophylactic vaginal douche 
became a routine part of the conduct of labor, in the belief that by its 
means the countless pathogenic microorganisms supposed to exist in the 
vaginal secretion of pregnant women could be destroyed, or at least 
rendered innocuous, and the risk of auto-infection minimized. Experi¬ 
mental work, however, has shown that, with the exception of the gono¬ 
coccus, the vaginal secretion at the end of pregnancy rarely, if ever, 
harbors pyogenic bacteria, and that the prophylactic vaginal douche is 
unnecessary. Furthermore, clinical experience has demonstrated that 
it is not only useless but even directly harmful, as its routine employ¬ 
ment is followed by a greater incidence of febrile cases during the 
puerperium than when it is omitted. This question will be dealt with 
more fully in the chapter upon puerperal infection. 

At the present time the vaginal douche is employed only exceptionally 
during pregnancy and labor; as, for instance, when the pregnant 
woman presents a profuse vaginal discharge due to gonorrheal infection. 
In such cases four liters of a hot 1 to 10,000 bichlorid or permanganate 
solution may be injected into the vagina twice daily during the last 
few weeks of pregnancy, not so much in the hope of curing the disease 
as avoiding infection of the child’s eyes during labor. This is all that 
can reasonably be expected, inasmuch as the gonococci have usually 
invaded the glands of the cervical canal, where they are protected from 
the action of the antiseptic fluid. 

Formerly, the employment of a prophylactic vaginal douche was 
recommended if the patient had been subjected to repeated examinations 
during labor by persons who habitually neglect ordinary aseptic precau¬ 
tions, and particularly if signs of infection are present. Owing to the 
impossibility of thoroughly disinfecting the vagina by antiseptic solu¬ 
tions, the value of such a procedure is questionable; although a douche 
of several liters of hot sterile salt solution can do no harm. 

After the first week of the puerperium, the vaginal douche is fre¬ 
quently employed when the lochia present an offensive odor. It need 

537 



538 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY 

hardly be said, however, that it is of but little value as a disinfectant, 
hut merely removes mechanically the secretion collected in the vagina, 
and thus adds materially to the comfort of the patient. Sterile salt 
solution, or a weak solution of carbolic acid, either alone or combined 
with boric acid and a little oil of peppermint, may be employed. 

Occasionally, when a puerperal infection has become localized, and 
has given rise to induration at the base of the broad ligament or in 
Douglas’s culdesac, the application of heat by means of abundant douches 
of hot boiled water or salt solution alleviates suffering, hastens the 
maturation of the abscess, and prepares the way for its prompt evacu- 
ation. 

Before giving a vaginal douche, the external genitalia should be 
carefully cleansed and the patient placed upon a douche pan as she 
lies in bed, or brought to the edge of the bed and placed in the obstet¬ 
rical position with a rubber pad beneath her. A fountain syringe, 
containing four quarts and provided with an appropriately shaped glass 
nozzle, previously sterilized by boiling, is employed, and the fluid allowed 

to run in under 
moderate gravity 
pressure. For the 
first days of the pu- 
erperium rigid asep- 
Fig. 454.—Glass Douche Tube. tic precautions should 

be observed in the 

use of the vaginal douche, and its administration should not be intrusted 
to the nurse, unless one is assured of her competency. 

Intra-uterine Douche .—The intra-uterine douche is not employed so 
long as the uterine cavity is occupied by the product of conception, but 
is frequently used immediately after labor and during the puerperium. 

Formerly it was customary to give an intra-uterine douche after all 
obstetrical operations. Such a procedure, however, is indicated only 
when the patient has exhibited signs of infection during labor; in these 
cases an intra-uterine douche of several liters of hot salt solution given 
after the completion of the third stage does no harm and occasionally 
may be productive of good. 

The most usual indication for its employment immediately after 
labor is afforded by postpartum hemorrhage due to atony of the uterus. 
In such cases the administration of a douche of 4 or 5 liters of hot 
sterile salt solution will usually lead to efficient and permanent con¬ 
traction, provided that no fragments of the placenta are retained in 
utero. 

The intra-uterine douche is also frequently employed during the 
puerperium, especially in the presence of infection. It has, however, 
been greatly abused: for, while it must be admitted that it may be 
useful in mechanically removing debris from the uterine cavity, it is 
nevertheless true that it may be directly harmful. For these reasons 
great care should be taken in the selection of the cases in which it is 
employed. Generally speaking, it is contra-indicated in all cases of 
streptococcic infection, inasmuch as the necessary manipulations may 





CURETTAGE 


539 


give rise to an extension of the process. On the other hand, when the 
symptoms are due to infection hv the so-called putrefactive organisms, 
associated with retention of the lochial discharge, the introduction into 
the uterus of several liters of hot salt solution is frequently followed 
by an immediate fall of temperature and a permanent improvement 
in the condition of the patient. If a single douche does not bring 
about the desired result, its repetition is generally useless. 

Sterile salt solution should be employed for intra-uterine douching, 
instead of the antiseptic solutions which were formerly recommended; 
since the latter, no matter how strong they may be made, can act only 
in a purely mechanical way, and cannot destroy the bacteria which 
have already invaded the endometrium. On the other hand, their use 
occasionally causes the death of the patient, and particularly when 
bichlorid of mercury was employed, the literature contained the 
records of many deaths from mercurial poisoning following the intra¬ 
uterine use of such solutions. 

Inasmuch as the administration of an intra-uterine douche must 
always be regarded as a serious matter, it should be given by the physi¬ 
cian himself and not delegated to the nurse, no matter how competent 
she may be; since the most rigid aseptic precautions are necessary, and 
failure in this regard may result in additional infection of the patient. 
As a preliminary, the vagina should be douched out. Two fingers 
having then been employed to locate the external os, the douch-tube 
is passed through it until it impinges upon the fundus of the uterus. 
Four or five liters of fluid are then slowly injected, care being taken 
to insure a free return flow. 

During the puerperium the cervical canal rapidly diminishes in 
caliber, and, owing to the marked anteflexion of the uterus which fre¬ 
quently occurs in this period, may become so bent as to offer a consid¬ 
erable obstacle to the introduction of the nozzle. To overcome this 
difficulty, traction should be made upon the anterior lip of the cervix 
by means of a pair of bullet forceps, when the cervical canal becomes 
straightened out. Occasionally, the contraction ring offers an obstacle, 
and the nozzle is arrested in the collapsed lower uterine segment. By 
making traction upon the cervix, and cautiously moving the extremity 
of the douche-tube, it can usually be passed into the uterine cavity 
without further difhcultv. 

Curettage.—By this term is understood the removal of the lining 
membrane of the uterus by means of a curette. The operation may be 
indicated in three conditions: incomplete abortion, imperfect involution 
of the puerperal uterus, and certain cases of infection. 

When portions of the placenta and membranes are retained within 
the uterus after an incomplete abortion, many authorities recommend 
their removal by means of a dull curette. As a preliminary, the cervix, 
if not sufficiently pervious, must be dilated by a suitable instrument, 
preferably that of Goodell or ITegar (see Fig. 343). The blunt curette 
is then introduced into the uterus and gently scrapes off the retained 
structures. The employment of an instrument, however, is rarely advis¬ 
able, as it is far better to peel off the adherent placenta and membranes 


540 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY 


with a finger, whose movements are controlled by the other hand, through 
the abdominal walls. After they are once loosened, the retained struc¬ 
tures can be readily removed by means of the finger or by an ovum or 
placental forceps. The former procedure necessitates the introduction 
of the entire hand into the vagina, and can only be accomplished under 
anesthesia. 

After the uterus has been emptied in such cases, the finger is again 
introduced and carefully palpates its cavity, in order to make sure that 
the offending structures have been entirely removed and thereby to 
avert all danger of subsequent hemorrhage. If the curette alone is 
used, considerable portions of placenta may be left behind, which may 
later give rise to bleeding and necessitate another operation. On 
numerous occasions I have seen patients in consultation in whom hem¬ 
orrhage had persisted after curettage, and on examination found that 
considerable portions of the placenta, or even the entire ovum, had been 
left in the uterus, the physician having removed only a part of the 
decidua at the previous operation. Moreover, curettage always carries 
with it the possibility of perforating the uterus, the walls in many cases 
being so soft and friable that the accident may occur despite the exercise 
of the utmost caution. Fortunately, the injury is generally attended 



Fig. 455. —Curette. 


by but little danger, although, if the uterine contents be infected, it 
may give rise to fatal peritonitis; again, in rare cases, a loop of gut 
may prolapse through the rent in the uterus and necessitate a major 
operation. 

Probably the most justifiable indication for curettage in obstetrical 
practice is the loss of blood after the first two weeks of the puerperium, 
resulting from imperfect involution of the uterus, which is sometimes 
associated with the retention of portions of the placenta or membranes. 
In such circumstances the operation gives excellent results, provided it 
be carried out in an aseptic manner. 

Formerly most authorities recommended curettage in puerperal in¬ 
fection, in the belief that by its means the focus of infection could 
be removed. The operation is undoubtedly beneficial in a certain number 
of cases, but should be instituted only in the presence of definite indi¬ 
cations, as its routine employment is frequently more dangerous than 
the original infection, and has led to the death of many hundreds of 
women. Generally speaking, it is contra-indicated when the infection 
is due to the streptococcus, as under such circumstances the lesions 
attending its use simply offer new areas for infection. On the other 
hand, it is often followed by excellent results when the so-called pu¬ 
trefactive organisms are producing the mischief, and particularly when 
the uterine cavity contains necrotic tissue or larger or smaller portions 
of degenerated placenta. Nevertheless, even in this class of cases it 
is generally better to employ the fingers in emptying the uterus. 




THE TAMPON OR PACK 


541 



The Tampon or Pack. —The vaginal tampon is occasionally indicated 
in the following conditions: inevitable abortion, certain cases of placenta 
previa, and to dilate the cervix in the early months of pregnancy. 
Profuse hemorrhage occurring in the early months of pregnancy usually 
indicates that abortion is inevitable. In such cases, if the cervical canal 
is not sufficiently dilated to admit the finger, and instrumental dilatation 
does not seem indicated, it is sometimes advisable to pack it and the 
vagina tightly with sterile gauze. When the packing is removed twelve 
or twenty-four hours later, the product of conception is frequently found 
lying free in the vaginal 
vault, and when this does 
not occur the cervical 
canal will usually be 
sufficiently dilated to 
permit the introduction 
of the finger, by means of 
which the uterus can he 
emptied. 

In placenta previa . 
when the hemorrhage is 
alarming and the cervical 
canal is not sufficiently 
dilated to admit a finger, 
certain authorities rec¬ 
ommend the application 
of a tight tampon to the 
cervical canal and vagina. 

I have never employed it 
in such circumstances, 
hut it is claimed that it 
effectually controls hem¬ 
orrhage, and on removing 
the pack a few hours 
later the cervix will usu¬ 
ally he sufficiently dilated 
to admit two fingers, after 
which combined version 
by the Braxton Hicks 
method can be performed, 
or a Champetier de 
Kibes’s balloon intro¬ 
duced. 

In the early months of pregnancy a tightly applied pack offers an 
uncertain means of dilating the cervix in any condition which demands 
the evacuation of the uterine contents, and rapid instrumental dilata¬ 
tion appears undesirable. In such cases, however, I prefer to evacuate 
the uterine cavity in one sitting by means of vaginal hysterotomy. 

The best material for a vaginal tampon is gauze, which is most 
conveniently handled in the shape of roller-gauze bandages 4 inches 


Fig. 456.- 


-Packing the Uterus for Postpartum 
Hemorrhage. 


















542 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY 


wide, which, have previously been carefully sterilized. For the intro¬ 
duction of the pack, the patient should be brought to the edge of the 
bed and prepared as for an operation. A bivalve, or preferably a 
Simon speculum is then introduced into the vagina and the cervix 
brought into view by means of a bullet forceps. Then with a long, 
dressing forceps the bandage is carried up and tightly packed into the 
cervical canal, and afterward into the fornix, so that eventually the 
entire vagina is completely tilled with it. 

Intra-uterine Pack. —Diihrssen, in 1887, advocated packing the uter¬ 
ine cavity with iodoform gauze as a means of controlling hemorrhage. 
Whenever there is persistent loss of blood following the third stage of 
labor, which does not yield to the ordinary methods of treatment, this 
procedure offers a most efficient method of controlling it, as the pack 
not only exerts pressure upon the bleeding vessels, but mechanically 
stimulates the uterus to renewed contraction. Plain sterilized gauze 
is preferable to that impregnated with iodoform or other antiseptics. 
It is most conveniently prepared for use in the shape of strips 8 yards 
long, each folded four times upon itself so as to give a bandage-like 
arrangement four inches wide, with the free edge hemmed, and with a 
tape attached to one end to facilitate its withdrawal. Six such packs 
should be sterilized in a package and a number of packages always 
kept available for immediate use. 

Before resorting to this procedure, however, it is essential that the 
hand be introduced into the uterus in order to ascertain that the 
hemorrhage is not due to retention of portions of the placenta. If 
the uterus is empty, after the usual preparations for an operation have 
been carried out, one blade of a Simon speculum is introduced and 
the posterior vaginal wall retracted; the anterior lip of the cervix is 
then seized with a bullet forceps and drawn down as near as possible 
to the vulva, after which sterilized bandages are rapidly packed into 
the uterine cavity by means of a long dressing forceps, the upper part 
of the vagina being also tamponed (Fig. 456). R. W. Holmes in 
1902 devised a tubular device for packing the uterus, which I have 
employed with great satisfaction. This consists of a tube approximately 
30 cm. in length, w r ith a bore 2 cm. in diameter, slightly curved so 
as to conform to the shape of the birth canal, and provided with 
an obturator and a pronged staff. With the obturator in place, the 
instrument is carried up into the uterus until its end impinges upon 
the fundus, the obturator is then removed, the gauze introduced into 
the free end of the tube and rapidly fed into the uterus by means 
of the pronged packer. This device makes unnecessary the use of a 
speculum and bullet forceps, has the advantage of reducing to a mini- 
jnum the possibility of contamination by contact with the external 
genitalia, and greatly increases the rapidity with which the pack can be 
applied. However it has been introduced, the pack should be allowed to 
remain in place not longer than twenty-four hours, on account of the 
danger of infection. Removal is readily effected by traction upon the 
tapes, and one should make certain that the number of packs removed 
corresponds to that introduced. 


MANUAL REMOVAL OF THE PLACENTA 


543 


Manual Removal of the Placenta.—V hen considering the treatment 
of the third stage of labor, it was pointed out that previous to the 
introduction of Crede’s method of expressing the placenta its manual 
removal was frequently resorted to. With increasing knowledge as to 
the proper conduct at this time, however, the operation became less 
and less frequently demanded, so that at present competent obstetricians 
consider that it is indicated only once in several hundred cases, and 
then only when abnormal adhesions exist between the placenta and the 
uterine wall, or when one has to do with a placenta membranacea or 
succenturiata. 


Manual removal is indicated whenever there is alarming hemorrhage 



Fig. 457. —Manual Removal of the Placenta. 


and the placenta cannot be expressed by Crede’s method, though such 
a condition is but rarelv observed. On the other hand, if there is no 
hemorrhage, the operation should not be resorted to merely to hasten 
the completion of the third stage of labor. Generally speaking, in 
such cases, repeated attempts at expression by Crede’s maneuver should 
be persisted in for at least an hour, under anesthesia, if necessary, and 
manual removal resorted to only after prolonged effort has shown that 
more conservative methods are ineffectual. The procedure is attended 
bv a greater danger of infection than any other obstetrical manipulation. 
In the ordinary operations, such as forceps and version, the hand, when 
introduced into the uterus, is within the amniotic cavity, and conse- 















544 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY 


quently microorganisms which may have been introduced along with it 
are cast off when the after-birth is expelled; whereas, in manual re¬ 
moval of the placenta the hand is inserted between the foetal membranes 
and the uterine wall, and, in separating the placenta from its attach¬ 
ments, comes in direct contact with the thropibosed sinuses. The latter 
may be regarded as blood serum culture tubes awaiting inoculation, 
so that if pyogenic bacteria are introduced, abundant facilities for their 
further growth are offered. 

When the operation becomes necessary, the strictest attention should 
be given to every aseptic detail. The external genitalia should be most 
rigorously cleansed, the hands and forearms of the operator carefully 
redisinfected, and encased in freshly boiled rubber gloves. After grasp¬ 
ing the uterus through the abdominal wall with one hand, the other, 
lubricated with sterile vaseline, is introduced into the vagina and passed 
into the uterus, following the umbilical cord. As soon as the placenta 
is reached, its margin should be sought for, and the inner surface of 
the hand insinuated between its margin and the uterine wall. Then, 
with the back of the hand in contact with the latter, the placenta should 
be peeled off from its attachment by a motion similar to that employed 
in cutting the leaves of a book. After its complete separation, the 
placenta should be grasped in the entire hand, but not extracted imme¬ 
diately, the operator waiting until the uterus contracts down firmly 
over the hand, which should then gradually be withdrawn. 

Once again, the importance of a most rigid aseptic technic in 
carrying out this procedure must be emphasized. Naturally, when the 
obstetrician finds himself face to face with an alarming postpartum 
hemorrhage, his only thought is likely to be as to the most rapid method 
of checking it, without regard to details. But even in such cases, the 
hand should be at least encased in a freshly boiled rubber glove; for, 
if introduced into the uterus without proper precautions, the patient, 
although saved from death from hemorrhage, may succumb to infection 
a few days later. 


LITERATURE 

Holmes, R. W. A New Method of Tamponing the Uterus Post-Partum. Am. 
Jour. Obst., 1902, xlv, 245-250. 


SECTION VI 


PATHOLOGY OF PREGNANCY 

CHAPTER XXV 

ACCIDENTAL COMPLICATIONS OF PREGNANCY DUE TO DISEASE 

Pregnancy may be associated with certain diseases which result frcm 
the condition itself, or by others which are to be regarded as accidental 
complications. The latter may have existed before the inception of 
pregnancy, or may have been acquired during its course. 

As a rule, all diseases which subject the organism to a considerable 
strain are more serious when occurring in the pregnant woman. Thus, 
a lung which is partially destroyed or thrown out of function may 
suffice for the respiration of an ordinary individual, but be unable to 
respond to the added demands of pregnancy, particularly in the later 
months, when the enlarged uterus restricts the mobility of the dia¬ 
phragm. Similarly, many a woman is unaware of the existence of a 
cardiac lesion, or at least leads a very comfortable existence, until the 
increased demands upon the activity of the heart incident to pregnancy 
bring about broken compensation with its attendant symptoms. 

In general, it may be said that pregnancy exerts a deleterious influ¬ 
ence upon all chronic organic maladies, while its effect is usually less 
marked in acute infectious processes. The latter, however, frequently 
lead to premature delivery, and the additional physical strain attending 
the latter may render the course of the disease much less favorable. 

Pregnancy Complicated by Acute Infectious Diseases.— Smallpox .— 
Smallpox complicating pregnancy carries with it a more serious prognosis 
than at other times. Thus Vinay reported a mortality of 36 per cent, 
in 235 cases, as compared with 25 per cent, in the non-pregnant con¬ 
dition. The hemorrhagic form of the disease is particularly fatal in 
pregnant women, Mayer having recorded the loss of 13 consecutive cases. 

Moreover, smallpox exerts a deleterious influence upon the product 
of conception, although the incidence of abortion or premature labor 
varies with the severity of the disease, Queirel stating that it is almost 
universal in the hemorrhagic, and comparatively infrequent in the dis¬ 
crete, variety. This may be due to hemorrhagic changes in the decidua, 
or to the direct transmission of the disease to the foetus, with its subse¬ 
quent death and expulsion. The occurrence of intra-uterine smallpox 
is well authenticated, children being occasionally born in the eruptive 
stage of the disease or with distinct pock-marks; as in the case re- 

545 


546 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


ported by Puig y Roig, in which the mother presented no manifestations 
of the disease. Mauriceau is said to have been infected in this manner, 
and the condition was well known to John Hunter and Smellie. More¬ 
over, in double-ovum twin pregnancy it sometimes happens that one child 
is definitely pock-marked, while the other shows no signs of the disease. 

Bollinger first suggested the possibility of the transmission from 
mother to foetus of the protective influence of vaccinia, and stated that 
when the mothers are successfully vaccinated during pregnancy a certain 
number of the children fail to take when vaccinated soon after birth. 
Behm noted this insusceptibility once in 29 cases, and believed that it 
was due to the transmission of an immunizing substance through the 
placenta. Kolloch held similar views. On the other hand, most authori¬ 
ties are skeptical as to the possibility of such an occurrence, and con¬ 
sider that unsuccessful vaccination in young children indicates that 
they are refractory to its influence, or that the virus was of poor 
quality. In 4G cases reported by AYolff, Palm, and Gast there was 
not a single instance of successful intra-uterine transmission. 

Scarlet Fever .—It is generally believed that the pregnant woman 
possesses a certain immunity to scarlet fever. Braxton Hicks and 
others considered that this was demonstrated by the fact that the dis¬ 
ease occurs much less frequently during pregnancy than in the puer- 
perium. Olshausen, who also held this view, was able to collect from 
the literature only 7 cases of scarlet fever occurring in the former, as 
compared with 134 in the latter, period. It is quite possible, however, 
that many of the puerperal cases were not examples of true scarlet 
fever, confusion having arisen on account of the rash which sometimes 
occurs in puerperal infection. The correctness of this latter supposition 
is supported by the fact that many authors believe in the intercom¬ 
municability of the two diseases, a point that cannot be demonstrated 
until the materies morbi of scarlet fever has been discovered. 

When occurring in the early months of pregnancy, the disease fre¬ 
quently causes abortion. This accident is usually attributed to the high 
temperature of the mother, though in very rare instances it may be due 
to the direct transmission of the disease to the foetus, Ballantyne having 
recorded a case in which the child presented a characteristic rash at 
birth. This view, however, has never met with any general acceptation. 

Measles .—Measles is not a frequent complication of pregnancy, but 
when it occurs is very prone to cause premature delivery, which was 
observed by Klotz in 9 out of 11 cases. According to Fellner, the 
prognosis is much more serious during the puerperium than during 
pregnancy. It is stated that intra-uterine transmission of the disease 
to the foetus is now and again noted, Lomer, Fiori, and others having 
reported cases in which the child presented a characteristic eruption at 
birth. 

Cholera .—Pregnant women do not appear to be attacked by cholera 
more frequently than others, although they succumb more readily to 
the disease. Schiitz states that the mortality among them in the Ham¬ 
burg epidemic of 1892 was 57 per cent. 

The disease exerts a very deleterious effect upon pregnancy, 54 per 


ACUTE INFECTIOUS DISEASES 


547 


cent, of the cases, according to Schiitz, ending in abortion or premature 
labor. This may be due to various causes. One-third of the women 
suffering from cholera have uterine hemorrhage, which, when occurring 
during pregnancy, must be associated with changes in the decidua, 
Slavjansky having described a peculiar form of hemorrhagic endometri¬ 
tis. Moreover, in nearly every instance, the disease causes uterine 
contractions, supposed to result from the circulation of toxins in the 
blood. 

Tizzoni and Cantani are the only investigators who have demon¬ 
strated the transmission of cholera bacilli to the human foetus; but 
\ itanzi’s experiments render it probable that such an occurrence is 
quite frequent in animals. 

Typhoid Fever .—Typhoid fever is a serious, and often a dangerous, 
complication of pregnancy. Moreover, it increases largely the foetal 
mortality, abortion or premature labor occurring in from 40 to 60 per 
cent, of the cases. Formerly it was held that the death of the foetus 
and its subsequent expulsion were due to the high temperature charac¬ 
terizing the disease; but it is now known that it is usually due to 
the direct transmission through the placenta of toxins or of the bacilli 
themselves. Since F. W. Lynch, in my clinic, demonstrated the bacilli 
in the organs of a foetus aborted by a woman suffering from typhoid 
fever, we have repeatedly made similar observations, so that it is gen¬ 
erally admitted that the foetus succumbs to a typhoid septicemia. The 
literature upon the subject was collected by Knapp in 1909. 

Pneumonia .—The maternal mortality is materially augmented when 
pneumonia occurs during pregnancy, since the disease frequently leads 
to premature labor or abortion. This result is generally attributed to 
imperfect oxygenation of the foetal blood, though it is frequently due 
to the direct transmission of bacteria to the foetus, in whose organs 
pneumococci have been demonstrated by Levy, Netter, Carbonelli, Lu¬ 
ba rsch, and others. Premature labor is a very untoward complication 
in such cases, as the exertion incident to it subjects the already weakened 
maternal organism to so great an additional strain that death fre¬ 
quently results. 

When pneumonia develops during the last days of pregnancy or 
early in the puerperium, it is not unusual for pneumococci to be trans¬ 
mitted by means of the blood stream to the uterus where they give 
rise to hematogenous puerperal infection. Johnston and Morgan de¬ 
scribed such a case occurring in our service, and collected the literafure 
upon the subject up to 1922. 

Influenza .—Our experience during the panepidemic of 1918 shows 
that influenza constitutes an unusually serious complication of preg¬ 
nancy, more particularly when of the pneumonic type. T. W. Harris 
in a statistical study based .upon 1350 cases, found that the gross 
maternal mortality was 27 per cent., which increased to 50 per cent, 
when pneumonia developed. 4 he disease also has a most deleterious 
effect upon the pregnancy, which was interrupted in 26 per cent, of 
the uncomplicated cases, and in 52 per cent, of those accompanied by 
pneumonia. Moreover, when the disease ended fatally spontaneous 


548 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


termination of pregnancy occurred in 62 per cent, of the cases before 
the death of the mother. 

In other words, the occurrence of abortion or premature labor adds 
to the gravity of the disease—a fact, which, in our judgment, effectively 
demonstrates the unjustifiability of terminating pregnancy artificially 
in the hope of improving the prognosis for the mother. On the other 
hand, in many of the mild cases, the disease runs a benign course, and 
has no effect upon the pregnancy, thereby partially confirming the 
opinion of Bar and Boulle that it is almost without influence upon 
the course of gestation. 

Erysipelas and Sepsis .—Erysipelas is a very serious disease at any 
time, but is particularly dangerous when occurring in pregnant women, 
in whom the possibility of a streptococcic puerperal infection is markedly 
increased. That this does not always occur is shown by the fact that 
I have delivered several women suffering from severe facial erysipelas 
without the occurrence of uterine infection. Occasionally, as noted by 
Lebedeff, the streptococci, the cause of the erysipelas, are transmitted 
from mother to child, but this is unusual. A general septicemia some¬ 
times follows a streptococcic angina, and in such cases streptococci can 
be found in the uterine lochia, as well as in the foetal blood. 

Furthermore, as a rule, any septic condition offers a worse prognosis 
in pregnancy than at other times. Kronig has reported several instances 
of transmission of the offending bacteria to the child, having demon¬ 
strated the transmission of colon bacilli from a parametritic abscess. 
He also made similar observations in an infectious process due to an 
anaerobic bacillus. 

Gonorrhea .—The occurrence of gonorrhea in the pregnant woman 
should never be lightly regarded. In not a few instances the organisms 
invade the decidua and give rise to inflammatory conditions which lead 
to abortion. Gonococci have been demonstrated in decidual endometri¬ 
tis by Neumann, Maslovsky, myself, and others. 

More important, however, are the consequences of gonorrheal infec¬ 
tion at the time of labor and during the puerperium, leaving out of 
consideration ophthalmia neonatorum, to which reference has already 
been made. After labor the gonococci, which have remained limited to 
the cervical canal during pregnancy, may gain access to the uterine 
cavity and give rise to febrile phenomena. The condition, although 
rarely fatal, is always serious, and will be considered in detail in the 
section on Puerperal Infection. In rare instances the gonococcus may 
produce a general infection, Dabney and Harris, and J. T. Smith having 
reported fatal cases of gonorrheal endocarditis observed in women de¬ 
livered at the Johns Hopkins Hospital. 

Tetanus .—Always a very dangerous disease, tetanus is fortunately 
a rare complication of pregnancy, nor does it appear to be more fatal 
than in non-pregnant women. Archambaud has reported a case which 
terminated favorably. 

Anthrax. —Anthrax, or malignant pustule, is rarely observed in 
human beings under any circumstances, but is almost always fatal. 
Rostowzen met with three deaths in pregnant women, and was able in 





CHRONIC INFECTIOUS DISEASES 


549 


each case to demonstrate anthrax bacilli in the tissues of the child. A 
similar observation was made by Paltauf. Ahlfeld and Marchand have 
reported a case in which a child, born of a mother suffering from 
anthrax, died a few days after birth from the same disease; but in 
this instance it was not clear whether they had to do with intra-uterine 
transmission or post-natal infection. In certain animals, on the other 
hand, the placental transmission of anthrax can frequently be demon¬ 
strated experimentally. The first observations of this character were 
made by Strauss and Chamberlent in 1882. 

Pregnancy Complicated by Chronic Infectious Diseases.— Tubercu¬ 
losis .—Formerly it was believed that pregnancy exerted a temporarily 
beneficial effect upon tuberculosis, the mother improving as long as she 
carried the child, though she frequently succumbed rapidly after its 
birth. At present, however, it is generally conceded that its effect is 
almost always harmful. Moreover, the strain incidental to labor and 
the extra drain upon the system, if the child is suckled, pull such patients 
down still further, so that the final result is usually hastened. 

On the other hand, the disease does not appear to predispose to 
premature interruption of pregnancy, and it is not unusual for tubercu¬ 
lous patients to give birth to splendidly developed children at full term. 

Occasionally tuberculosis may be transmitted from mother to child. 
Hauser (1898) collected from the literature 18 cases in which the trans¬ 
mission of tubercle bacilli was definitely demonstrated. Since then 
many additional cases of congenital tuberculosis have been recorded, 
and their significance particularly considered by Chome, and Whit¬ 
man and Greene. The latter have collected 38 cases with charac¬ 
teristic histological findings, as well as 21 cases in which bacilli could 
be demonstrated in the foetus and placenta, and three in the foetus 
only, but as no histological lesions were present it appears doubtful 
whether the latter can be classified as examples of congenital tuberculosis. 
In this condition the infection usually occurs through the placenta by 
means of the blood current, as is proven by the fact that the most 
advanced lesions are usually situated in the liver. 

Following the description by Lehmann of the first cases of placental 
tuberculosis, the subject has been carefully studied by many investi-' 
gators. Novak and Ranzel, collected 39 such cases in 1910, while 
Whitman and Greene increased the number to 47 in 1922. As the 
former investigators found tubercle bacilli in 7 out of 10 placentae 
from women in various stages of the disease, it is apparent that the 
condition occurs more frequently than is generally believed, and con¬ 
firms the opinion of Baumgarten and Maffucci that the incidence of 
congenital tuberculosis is generally underestimated. According to Lanz 
tubercular lesions of the placenta may occur in the following forms: 
(1) tubercles attached to the periphery of the chorionic villi, but pro¬ 
jecting in great part into the intervillous spaces; (2) tubercles in the 
stroma of the villi, which are due to bacilli which have penetrated 
the villous epithelium; (3) tubercular changes in the chorionic mem¬ 
brane, and (4) caseous tubercular deposits in the decidua basal is. Of 
these, (1) and (4) are the most frequent, while (2), which is the 



550 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


lesion most concerned in the production of congenital tuberculosis, has 
only occasionally been observed. 

The possibility of germinal infection should also be borne in mind. 
Friedmann in experiments upon the rabbits and guinea pigs showed that 
tubercle bacilli may be carried to the ovum by means of the spermato¬ 
zoa; while Sitzenfrey has demonstrated in women dying from tubercu¬ 
losis the presence of bacilli in the interior of ova while still within 
the graafian follicle. It is, of course, questionable whether such infected 
ova would go on to development, but should it occur, the supposition 
that the bacilli might lie dormant for some time would afford a plausible 
explanation for the cases in which the tuberculosis does not become 
manifest until some time after birth. 

When one considers, however, the large number of tuberculous wo¬ 
men who become pregnant, and the relatively small proportion of cases 
in which the transmission of the disease to the foetus has been demon¬ 
strated, it is apparent that the latter must be an exceptional occurrence. 
Evidence in favor of this view was supplied by one of my patients, who 
died from tuberculosis a short time after delivery and in whose lochia 
tubercle bacilli could be demonstrated during life. At autopsy the 
child showed no signs of the disease, nor did the lining membrane of 
the uterus present any tuberculous lesion. 

It would appear, therefore, that in the vast majority of cases the 
disease is not transmitted directly from the mother to the foetus, but 
that the latter is born with lessened resistance to tuberculosis rather 
than with the disease itself. Hence it follows that such children should 
be brought up under the best hygienic surroundings and should not be 
suckled by their mothers. 

In view of the fact that the tuberculous process usually becomes 
exacerbated either during pregnancy or after childbirth, most authori¬ 
ties recommend that abortion be induced as a matter of routine in all 
tuberculous women, and many that they be rendered sterile by operative 
means. This appears to be a somewhat too extreme point of view, but 
I feel very strongly that abortion should be induced in the first preg¬ 
nancy occurring after the onset of the disease, or whenever it makes its 
appearance during the early months of pregnancy, in order to give the 
patient every opportunity to place herself under such dietetic and cli¬ 
matic conditions as may offer every chance of curing or arresting the 
disease, rather than to run any risk of its exacerbation after labor. 
If the patient is intelligent, she and her husband should then be warned 
of the danger of future pregnancies until the process has become either 
arrested or cured, and the necessary contraceptive advice given. Should 
conception occur in spite of the warning, I hold that repeated abortion 
is indicated only in exceptional instances; as otherwise the obstetrician 
may find himself called upon to repeat the operation at frequent inter¬ 
vals. On the other hand, with unintelligent patients such advice is 
useless, and the propriety of sterilization by operative means should be 
considered. When the pregnancy is far advanced, I do not consider 
the induction of premature labor justifiable, as experience teaches that 
its effect upon the patient is quite as deleterious as labor at term, 


CHRONIC INFECTIOUS DISEASES 


551 


while the chances for the child are greatly diminished. Exceptionally, 
if the mother is so ill that it seems improbable that she will live until 
the end of pregnancy, the operation may be performed solely in the 
interest of the child. 

Malaria .-—Despite the somewhat widespread opinion to the contrary, 
it would appear that the ordinary forms of malaria have but little 
influence upon the course of pregnancy, although Goth has reported 
that 19 out of 46 cases ended in premature labor, and Edmonds states 
that this accident is very common in Africa. 

Some years ago I studied 15 cases of malaria complicating preg¬ 
nancy, the diagnosis being assured by the demonstration of the charac¬ 
teristic plasmodium. None of these patients aborted, and in but two 
did pregnancy end prematurely, and then only a week or so before term. 
It is probable, however, that the pernicious forms of malaria may have 
a much more deleterious effect. There is a marked tendency toward 
recrudescence of the disease during pregnancy and the puerperium, just 
as is frequently observed after surgical operations. 

Quinin should be administered unhesitatingly to women suffering 
from malaria during pregnancy, as its oxydoxic properties are appar¬ 
ently in abeyance under such conditions, so that it can be used with 
impunity without fear of setting up uterine contractions. 

Syphilis .—Syphilis is one of the most important complications of 
pregnancy, as it is the most frequent single cause of foetal death. In 
1915, I reported that it was responsible for 26.4 per cent, of the 705 
foetal deaths occurring in 10,000 consecutive labors under my super¬ 
vision. These figures include all deaths occurring after the period of 
viability has been reached, as well as during the first two weeks fol¬ 
lowing labor. Thev do not, however, tell the whole story of the ravages of 
the disease, for many children who were discharged alive, either died soon 
afterwards or presented manifestations of hereditary syphilis later in 
life. Furthermore, syphilis was demonstrated as the etiological factor 
in 40 per cent, of our dead-born premature infants and in approxi¬ 
mately 80 per cent, of the macerated children, and consequently should 
be suspected whenever a perfectly satisfactory explanation for the oc¬ 
currence of premature labor cannot be adduced. On the other hand, 
it plavs but a small part in the causation of early abortion. In 1920, 
I reported that a positive Wassermann reaction was present in 11.2 per 
cent, of 4547 consecutive women passing through our service, but that 
such findings were less frequent in the white than in the black patients 

—2.5 and 16.3 per cent, respectively. 

When infection occurs during pregnancy, owing to the vascularity 
of the parts, the initial sore may assume larger proportions than under 
ordinary circumstances. The secondary lesions, however, are often but 
slightly marked, and may be practically limited to the genitalia, where 
they appear as large, elevated areas which occasionally undergo ulcera 
five changes, and sometimes lead to the destruction of superficial por¬ 
tions of the vulva. In many patients, however, no history of a primary 
sore or of a rash can be elicited, and the first intimation of the 
existence of the disease is afforded by the birth of a premature or 








552 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


macerated foetus, or by the demonstration of a positive Wassermann 
reaction. 

The influence of syphilis upon pregnancy differs materially, and three 
classes of cases are distinguished, according as infection has taken place: 
(1) before pregnancy; ( 2 ) at the time of conception, or (3) during 
pregnancy. 

The syphilitic child is often dead when it comes into the world; 
less frequently it is born alive with definite manifestations of the 
disease. Again, in a still smaller number of cases, it may be born 
without signs of the disease, which, however, make their appearance 
later; while occasionally, particularly when the infection had occurred 
some years previously, the child may never manifest any signs of the 
disease. Moreover, my investigations have shown that syphilis is the 
actual cause of death in many children, which were apparently normal 
at birth, but succumbed some weeks later to what is usually designated 
as inanition or marasmus. 

When inoculation with the specific poison has occurred before con¬ 
ception, and is not treated, the disease usually causes premature labor 
or the expulsion of a macerated foetus. Le Pileur obtained a striking 
illustration of the disastrous effects of syphilis from a study of the 
reproductive histories of 130 women before and after its inception, 3.8 
per cent, of the children being born dead before, as compared with i 
78 per cent, after, infection. 

When the mother is suffering from the affection at the time of 
conception, the offspring is always syphilitic. The same applies when 
the infection and conception occur at the same time. On the other 
hand, when syphilis is contracted during pregnancy, its effect upon ■ 
the foetus varies. If infection occurs within the first few months, the 
foetus, as a rule, likewise manifests signs of the disease, but when it 
occurs later the child may not become infected. 

Until recently it was generally believed that foetal syphilis was 
frequently the result of paternal infection, and that a man suffering 
from the tertiary form might engender a syphilitic child without in¬ 
fecting his wife. This belief was based upon the observation that an i 
apparently healthy woman might give birth to a definitely syphilitic 
child, and be able to suckle it with impunity, whereas it would certainly 
infect another woman. Such an occurrence was well stated in the dictum 
known as Colie’s law, assuming spermatic infection and a transmission 
of immunity from foetus to mother. Conversely, it was also believed 
that a definitely syphilitic mother might occasionally give birth to a 
healthy child, which would possess a definite immunity against the 
disease. Such observations gave the basis for Profeta’s law. 

With the discovery of the Spirochaeta pallida by Schaudinn, and the 
utilization of the Wassermann reaction as a means of diagnosis, grave 
doubt has been cast upon the validity of these laws, which are now 
denied by the great majority of syphilographers. In order for paternal 
transmission to occur it is necessary to suppose that the syphilitic virus 
is transmitted to the ovum by means of the spermatozoon. As long as the 
virus was merely hypothetical this did not seem improbable; but when 





CHRONIC INFECTIOUS DISEASES 


553 


Bab pointed out that the spirochete is three times as long as the head 
of a spermatozoon, it appeared unlikely that the former could enter the 
ovum along with the latter, unless some sporelike intermediate form 
exists. Recent investigations concerning other varieties of spirochetes, 
of which mention was made by Strong in 1923, make it conceivable that 
this may be the case; as not a few investigators believe that a so-called 
granular stage represents an important phase in the life-cycle of certain 
spirochetes. Moreover, Sergent and Foley have shown that monkeys can 
be infected with recurrent fever by the injection of human blood which 
contains no visible spirochetes, and consequently hold that the virus of 
the disease may exist in the blood of man and of the louse in a very 
minute form. Whether similar observations will be made for the spiro- 
chaeta pallida remains to be seen. Furthermore, the fact that the appar¬ 
ently healthy mothers almost universally present a positive Wassermann 
reaction has led most investigators to conclude that the immunity is only 
apparent, and is due to the fact that such women are really suffering from 
a latent syphilis, which has not given rise to symptoms. 

It must he admitted that these arguments greatly impair the validity 
of Colles’s law, as its acceptance implies the existence of a granular 
form of the spirocheta, as well as the supposition that a positive maternal 
Wassermann may be due to “immunizing substances” derived from the 
syphilitic ovum. Nevertheless, I am not prepared to deny such possi¬ 
bilities, for the reason that Colies’s law seems to offer a plausible explana¬ 
tion for certain definite clinical manifestations, and also because I can¬ 
not rid myself of the idea that the constant casting off into the maternal 
circulation of minute portions of the paternally infected ovum—in the 
shape of fragments of chorionic villi—would seem to offer an almost ideal 
means of bringing about active immunity. Boas is the only syphilog- 
rapher who shares my views, and he states that the question is still sub 
judice. Moreover, both he and Fildes hold that syphilis on the 
part of the mother does not necessarily imply infection of the foetus, and 
have adduced a considerable mass of figures in support of their con¬ 
tention. 

Consideration of the syphilitic lesions of the child and the placenta 
will be taken up in the chapter upon Diseases of the Ovum. 

Whenever we obtain a history of syphilis in either parent, no matter 
whether infection has occurred prior to or after conception, the mother 
should at once be treated by salvarsan, followed by a course of specific 
treatment; as by its means not only may she be cured, but, in view of 
the fact that the arsenical and mercurial salts, as well as iodid of potas¬ 
sium, are readily transmitted through the placenta, the foetus is treated 
at the same time. 

In hospital services for ward patients, one of the most important func¬ 
tions of prenatal care is the recognition and treatment of the syphilitic 
pregnant woman. As the great majority of such give no history of infec¬ 
tion and present no visible manifestations of the disease, this can be 
accomplished only by routinely taking a sample of blood for a Wasser- 


554 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


mann test at the first visit. From our own experience, it is safe to say 
that if efficient treatment is instituted by the fifth month of pregnancy 
congenital syphilis can be almost entirely eliminated. Furthermore, the 
pregnant woman is unusually susceptible to its influence, so that it fre¬ 
quently happens that an amount of treatment which would be useless 
in the case of a man, makes the difference between the birth of an infected 
or a normal child. 

The treatment, however, cannot be regarded as efficient, unless the 
Wassermann reaction has remained persistently negative for at least one 
year after the administration of the last course of salvarsan. Conse¬ 
quently, the birth of an apparently normal child should be followed by 
sufficient additional treatment to insure the complete cure of the mother. 
In practice of the better class, the routine Wassermann is probably not 
necessary, and for the present, at least, should be restricted to those pre¬ 
senting a history of previous premature labors, or the birth of macerated 
children. 

In view of the practical application of Colles’s law, the syphilitic 
child may be suckled with impunity by its own mother. If, however, 
she is unable to nourish it, it should never be given to a wet-nurse, but 
should be fed artificially. 

Diseases of the Circulatory and Respiratory Systems .—Valvular Le¬ 
sions of the Heart .—While the work of Stengel and Stanton, and most 
recent authors, tends to show that little if any hypertrophy of the heart 
occurs during pregnancy, the investigations of James Mackenzie indicate 
that there normally occurs a certain amount of derangement in the 
cardiac function. He bases his conclusions upon the fact that the fol¬ 
lowing conditions may frequently be noted: (1) limitation of the field 
of cardiac response; (2) changes in the rate and rhythm of the heart; 
(3) dilatation of the right side of the heart ; (4) tendency to edema of 
the lungs; (5) tendency to overfilling of the veins of the legs, and (6) 
the occurrence of marked pulsation in the veins of the neck. As all of 
these conditions are more or less abnormal, and are likely to become 
greatly accentuated in pregnant women suffering from valvular lesions 
of the heart, there is good reason for considering such complications as 
serious. 

The gravity of valvular disease complicating pregnancy is generally 
over-estimated, and the mortality of 28 per cent, reported by Guerard, 
which led him to consider the complication as more serious than eclamp¬ 
sia or placenta previa, can be explained only by supposing that his 
material was made up almost entirely of cases in which compensation had 
long since failed, and did not include the mild and moderately severe 
cases which occur relatively frequently in large series of deliveries. The 
figures of Demelin, Vinay, Kellogg and Fellner indicate that the inci¬ 
dence of heart lesions complicating pregnancy varies between 1 and 2.5 
per cent., and that only about 2 per cent, of the entire number end 
fatally. In a^out three-fourths of the cases the condition is so mild that 
the woman is not aware of her condition, while in the remainder decom¬ 
pensation may develop with more or less serious results. 

In a series of 94 cases Fellner observed the following lesions: 


555 


CIRCULATORY AND 


R INSPIRATORY DISEASES 


Mitral insufficiency. 

Mitral stenosis. 

Combined mitral lesions. 

Aortic insufficiency. 

Aortic and mitral lesions 

Uncertain lesions. 

Myocarditis. 


37 

5 

34 

3 

10 

r 


He also stated that only one-seventh of such cases showed cardiac mani¬ 
festations. Mackenzie holds that systolic murmurs without signs of heart 
failure are of little significance, and that, while mitral stenosis is more 
serious, its prognosis is variable. If the process is stationary, the size of 
the heart normal, its rate regular and the response good, the prognosis 
is good; whereas, if associated with enlargement of the heart, poor 
response and fibrillation, it is very serious. 

From my own experience, I should say that apparently functional 
cardiac murmurs are frequently heard in pregnancy, while serious organic 
lesions occur once in several hundred cases, and are accompanied by 
dyspnea and edema during the latter part of pregnancy, and occasionally 
some degree of collapse is noted shortly after labor. On the other hand, 
one occasionally sees cases with broken compensation associated with such 
urgent symptoms that artificial interruption of pregnancy is clearly 
indicated. In several of my cases the symptoms were most alarming. 
One multiparous patient, suffering from uncompensated mitral disease, 
collapsed in the last month of pregnancy, with signs of acute dilatation 
of the heart and intense pulmonary edema. Death was averted by blood¬ 
letting and the induction of premature labor; while in others the con¬ 
dition was so alarming that cesarean section was performed. 

It is generally admitted that the most untoward symptoms are ob¬ 
served in mitral stenosis. Lusk regarded this lesion as sufficiently serious 
to warrant the induction of abortion as soon as the diagnosis is made. 
This, however, is too extreme a view, although it must be admitted that 
this lesion is more apt to give rise to serious disturbances than all others 
combined. Thus, Kautsky found that mitral stenosis, either alone or 
associated with insufficiency, was responsible for the entire mortality in 
his series of heart cases, and that the mortality was 28 per cent, when 
that lesion was present. On the other hand, French and Hicks, after 
studying the obstetrical records of 300 women treated in Guy’s Hospital 
for this condition, hold that it is no more serious than other lesions; and 
in support of their statement adduce the fact that 135 of their patients 
went through 608 labors without a break in compensation. 

Generally speaking, the prognosis is good so long as compensation 
is retained, whatever the lesion. To this, however, there are certain ex¬ 
ceptions, as Zweifel has recorded two cases in which collapse and death 
occurred in pregnant women who had previously been absolutely unaware 
of their condition. On the other hand, if compensation fails, and rest 
in bed and appropriate therapy do not bring about amelioration of the 
symptoms, the prognosis becomes ominous; for even if the patient be 
saved from immediate death by the induction of premature labor, or by 
cesarean section, serious complications are usually in store for her in the 
! future. 










55G 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


Grave heart lesions complicating pregnancy are generally believed to 
predispose to premature labor, which was noted in 20.2 per cent, of 
Fellner’s cases, as compared with 5.5 per cent, in those of French and 
Hicks. This accident may result from uterine hemorrhage directly at¬ 
tributable to the cardiac condition, from the death of the foetus due to 
insufficient oxidation, or from changes in the placenta. In not a few 
cases there is more or less profuse hemorrhage immediately following 
delivery; or again, at the time of labor, owing to the elevation of arterial 
pressure incident to the uterine contractions, compensation may fail 
and the woman’s life may be in peril. Moreover, collapse may manifest 
itself immediately after the expulsion of the child, as a result of the 
marked fall in the arterial pressure which occurs at that time. 

If the lesion is fairly compensated the patient should be kept under 
close observation, rest being ordered and digitalis or some other heart 
tonic being employed as soon as symptoms appear. If this treatment 
fails to bring about the desired result, pregnancy should be promptly 
ended by the most conservative method available. 

If the patient is allowed to go on to term, owing to the psychical 
disturbances incident to labor, and the elevation of arterial pressure 
brought about by the abdominal and uterine contractions, it is 
advisable to make use of an anesthetic during tthe second stage. As 
soon as the cervix is completely dilated and the head well engaged in the 
pelvis, the termination of labor by forceps is indicated. 

Some authorities recommend that women suffering from heart lesions 
should be dissuaded from marriage, or, if married, from becoming preg¬ 
nant. This, however, appears to be an extreme view, and should only 
apply when the lesion is serious and the compensation faulty. 

Myocarditis .—Owing to the difficulty in making an exact diagnosis, 
myocarditis is rarely recognized during life. Nevertheless, it is a most 
serious complication of pregnancy, and is one of the frequent causes of 
sudden death during the second stage of labor and the first few hours 
of the puerperium. 

Occasionally cases of tachycardia are observed during pregnancy for 
which no explanation can be given. Thus, in a multiparous patient the 
pulse-rate varied between 120 and 140 during the last three months of 
each pregnancy, but returned to normal within a few davs after deliverv. 
As a thorough physical and urinary examination failed to reveal any 
abnormality, I was forced to make the unsatisfactory and provisional 
diagnosis of neurotic tachycardia. 

Endocarditis .—Acute endocarditis may appear during pregnancy, I 
just as at other times. It should always be regarded as a serious matter, 
but particularly so at this time, as occasionally the bacteria giving rise 
to it may be transmitted to the foetus and cause its death, while in other 
cases small portions of the vegetations upon the valves may be broken off 
and give rise to apoplexy or embolism. 

Phlegmasia .—Thrombosis of the veins of the thigh, or phlegmasia, is 
a very rare complication of pregnancy. F. C. Goldsborough in 1904 
reported a case observed in my service and collected the literature upon 
the subject. Vhile there is no evidence that it is due to infection, as is 




CIRCULATORY AND RESPIRATORY DISEASES 


557 


the case with puerperal phlebitis, it should be regarded as a serious con¬ 
dition, particularly in view of the fact that incautious manipulations may 
lead to the detachment of small particles of a thrombus, which may then 
give rise to embolism of the pulmonary arteries. The symptoms and 
treatment are dealt with in Chapters XLIII and XLIY. On the other 
hand, thrombosis of the superficial vessels of the leg is frequently observed 
in women suffering from varicose veins, and can usually be regarded with 
equanimity. 

Pulmonary Embolism .—Embolism of the pulmonary arteries is a 
much rarer complication of pregnancy than of the puerperium. Barnes 
reports one case which ended fatally within a few moments, while 
Sperling has reported a second which eventuated in recovery. The con¬ 
dition should always be borne in mind in cases of sudden death during 
pregnancy which cannot otherwise be explained. 

Emphysema .—When pregnancy occurs in women suffering from ad¬ 
vanced emphysema, the dyspnea may become so intense as to demand 
its artificial interruption. In a certain number of cases premature 
labor occurs spontaneously, the untimely uterine contractions being at¬ 
tributed to insufficient aeration of the blood. 

Asthma .—The symptoms of asthma are sometimes markedly aggra¬ 
vated during pregnancy. In some patients the disease makes its appear¬ 
ance only during pregnancy or at the time of labor, disappearing spon¬ 
taneously after childbirth. If the usual methods of treatment fail, cure 
may sometimes be effected by placing the patient upon an absolute milk 
diet, although careful analysis of the urine may not indicate the exist¬ 
ence of a toxemia. If this is ineffectual, a radical change of air sometimes 
proves beneficial. 

Dyspnea .—Almost every woman in the last few weeks of pregnancy 
suffers more or less from shortness of breath resulting from interference 
with the motility of the diaphragm by the enlarged uterus. Dyspnea 
occurring in the earlier months of pregnancy is usually due to cardiac or 
renal disease, and demands a thorough physical examination. Occa¬ 
sionally it follows excessive distention of the uterus, as in hydramnios. 

Varices .—Owing to the pressure of the pregnant uterus upon the 
veins returning from the thighs, and the fact that they are but poorly 
supplied with valves, abnormalities in their circulation are frequently 
observed during pregnancy, and manifest themselves by the appearance 
of varicose veins. These may assume considerable proportions in the 
legs or about the vulva, and give rise to distressing symptoms. When 
situated in the latter location, their rupture may lead to fatal hemorrhage 
if medical aid is not available. When they occur in the legs, relief is 
often obtained by the use of neatly applied bandages or elastic stockings. 
Active treatment is useless in vulval varices, but the danger of their rup¬ 
ture should be borne in mind at the time of labor. 

Edema .—Edema is a very frequent complication of pregnancy. It 
may be general and involve any portion of the body, but is usually lim¬ 
ited to the lower extremities. Occasionally the vulva becomes intensely 
edematous. When limited to the extremities, the swelling was formerly 
attributed to pressure exerted by the enlarged uterus upon the veins 




558 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


returning from the legs, but Zangemeister considers it due to increased 
permeability of the capillaries, which he holds is part of a process peculiar 
to pregnancy—hydrops gravidarum—which is often the forerunner ol a 
true toxemia and manifests itself before the blood pressure becomes 
elevated or albuminuria appears. In not a few instances, the condition 
may be recognized by an excessive gain in weight days before manifest 
edema appears. On the other hand, if the condition be generalized, it is 
likely to be a manifestation of toxemia, though occasionally it may be 
due to other causes. 

The patient should be cautioned as to its significance, and whenever 
edema appears the urine should be carefully examined. If the kidneys 



Fig. 458.—Edema of Vulva. 


are found to he doing their work properly, the swelling is probably of 
mechanical origin and can be relieved only by restricting the movements 
of the patient, or even confining her to her bed. If the urinary findings 
indicate the existence of a toxemia, the condition is more serious, and 
should be treated as will be indicated in the following chapter. 

When the marked swelling about the vulva is a source of discomfort 
and annoyance, and is not relieved by medicinal treatment, relief may be 
given by puncturing the most dependent portions of the swollen labia 
and allowing the serum to drain off. This slight operation should 
always be done under the strictest aseptic precautions, and the labia after¬ 
ward covered with sterile dressings, inasmuch as infection can readily 
occur and may be followed by serious consequences. 















559 


DISEASES OF 


ALIMENTARY TRACT AND TIIE LIVER 


Diseases of the Alimentary Tract and the Liver.— Icterus. —Preg¬ 
nancy is comparatively seldom complicated by jaundice, which is usually 
due to cataYrhal processes in the duodenum or to cholelithiasis. The 
catarrhal variety is generally without significance and undergoes spon¬ 
taneous cure. At the same time, it should be borne in mind that jaundice 
may represent the onset of acute yellow atrophy of the liver; while its 



of profound lesions in the liver, and adds greatly to the seriousness of 
the prognosis; for this reason simple catarrhal icterus should not be 
diagnosticated, until a careful examination has excluded such possi¬ 
bilities. 

Epidemics of jaundice have been recorded in various portions of the 
world, in which the disease ran its usual course in men and non-pregnant 
women, but was disastrous in pregnancy, some of the women dying in 
coma and many more aborting or falling into labor prematurely. More¬ 
over, it would seem that pregnancy sometimes predisposes to the occur¬ 
rence of' jaundice, as Van der Velden and others have recorded instances 
in which it occurred in successive pregnancies and was frequently asso¬ 
ciated with hemoglobinuria. 

It is generally believed that women suffering from jaundice at the 
time of labor have a tendency to hemorrhage, but this was not noted 
in the few cases which I have seen. 

Gall-stones .—The fact that cholelithiasis occurs more frequently in 
women than in men would suggest a possible association with the repro¬ 
ductive function. Acute attacks may occur during pregnancy or the 
puerperium, and Peterson in 1910 collected 25 operations performed in 
the former, and 10 in the latter period. It is always a serious com¬ 
plication, and operation, if urgently demanded, should be undertaken 
without regard to the existence of pregnancy. In less urgent cases it is, 
of course, advisable to postpone interference until after the child has 
become viable. 

Acute atrophy of the Liver .—This condition will be considered in the 
chapter on the Toxemias of Pregnancy. 

Indigestion .—Pregnant women frequently suffer from indigestion, 
and the symptoms arising from it are sometimes very distressing. Kehrer 
is inclined to attribute them, at least in part, to the decrease in the 
amount of gastric hydrochloric acid, which he considers usual in preg¬ 
nancy. Such cases should be treated without reference to the existence 
of pregnancy. In many instances marked relief follows the adminis¬ 
tration of a wine-glass of cream a half hour before each meal. 

Constipation .—Owing to distention by the growing uterus, the ab¬ 
dominal walls may become so impaired in tonicity that considerable 
difficulty is experienced in evacuating the bowels. Indeed, it may be 
said that the majority of pregnant women suffer from constipation. 
This condition should be carefully guarded against in order to avoid 
auto-intoxication and increased strain upon the kidneys. It is best 
overcome by appropriate diet, regularity in going to stool, and the 
occasional use of pills of aloin, belladonna, and strychnin, the fluid 
extract of cascara, or compound licorice powder. Mineral oil by itself 



560 


ACCIDENTAL COMPLICATIONS 


DUE TO DISEASE 


does not give satisfactory results, but when taken in combination with 
the milder laxatives, it enables one to decrease the dose of the latter. 
The stronger cathartics should be avoided on account of their tendency 
to cause abortion. 

Enteroptosis. —The neurasthenoid symptoms which so frequently 
accompany enteroptosis are often markedly ameliorated during preg¬ 
nancy, inasmuch as the steadily enlarging uterus may tend to restore 
the displaced viscera to their normal positions. The comfort of the 
patient can be added to appreciably by the use of rational clothing, and 
especially by the application of a properly adjusted abdominal supporter. 
The condition, however, is prone to recur after childbirth unless the 
patient takes on considerable flesh. According to Maillart the improve¬ 
ment is sometimes permanent, especially if the relaxation of the abdom¬ 
inal walls be counteracted by the use of a snugly fitting binder during 
the puerperium and a suitable abdominal supporter afterward. 

Salivation. —In exceptional instances the salivary secretion becomes 
markedly increased during pregnancy. As a rule, this is not a serious 
complication, but now and again the amount of saliva is so great as to 
cause the patient great annoyance, and sometimes even prevent her from 
sleeping. One of my own patients expectorated between 500 and 600 
cubic centimeters of clear fluid every day for several weeks, while Lvoff 
has reported several cases in which the secretion in the twenty-four hours 
varied from 1,000 to 1,600 cubic centimeters. 

The condition is usually attributed to a reflex neurosis incident to 
pregnancy, but sometimes it is a manifestation of toxemia. In the first 
class of cases the treatment is very unsatisfactory, astringent mouth 
washes, and even comparatively large doses of atropin, being without 
effect. On the other hand, when the condition is a manifestation of 
toxemia, prompt amelioration may follow the use of a rigorous milk diet. 

It sometimes happens that the cloudy fluid which is supposed to be 
saliva, in reality represents regurgitated gastric secretion. My assistant, 
John G. Murray, Jr., had under his care a patient, apparently suffering 
from salivation, and who was daily excreting nearly a liter of fluid. 
Chemical examination in our laboratory revealed the surprising fact that 
the fluid presented an acid reaction, which was due to the presence of 
hydrochloric acid in the same proportion as in gastric juice. How fre¬ 
quent such an occurrence may be can only be determined by future in¬ 
vestigation. 

Gingivitis — Exceptionally, the gums of pregnant women become in¬ 
flamed and spongy, and bleed upon the slightest touch. The condition 
is usually observed in run-down individuals, and is very refractory to 
treatment, although in many cases it disappears almost immediately after 
delivery. It is best met by the employment of astringent mouth washes, 
especially those containing tincture of myrrh, combined with general 
tonic treatment and an abundant diet. 

Dental Caries. —Many women suffer during pregnancy from dental 
caries, which may be associated with more or less severe toothache. It 
is a popular belief that pregnancy predisposes to the condition, as is 
evidenced by the saying, “For every child a tooth.” It is probable that 




DISEASES OF THE KIDNEYS AND URINARY TRACT 


561 


the condition is somewhat allied to the minor degrees of osteomalacia 
which occur, only during pregnancy. Such patients should be referred 
to a skillful dentist, and at the same time should drink considerable quan¬ 
tities of milk, and take calcium chloride. 

Diseases of the Kidneys and Urinary Tract .—Chronic Nephritis .— 
Pregnancy occurring in patients suffering from chronic nephritis is 
always a serious complication, and will be considered in the chapter on 
the Toxemias of Pregnancy. 

Glycosuria and Diabetes. —Blot, in 1856, stated that sugar could 
usually be found in the urine of lactating women; but after it had been 
demonstrated that the condition was a lactosuria, the belief gained 
ground that the existence of true diabetes was inconsistent with con¬ 
ception. This view was first combated in 1882 by Matthews Duncan, 
who was able to find in the literature 22 cases in which pregnancy was 
complicated by diabetes, and he laid down the dictum, which received 
general acceptance, that such an association was extraordinarily serious. 

True diabetes is rarely noted in pregnant women, and may exist 
before the inception of pregnancy, or may occur during its course. The 
prognosis is generally believed to be ominous for mother and child. In 
the 66 cases which I collected, 27 per cent, of the mothers died at the 
time of labor or within two weeks afterward, while an additional 23 per 
cent, perished during the following two years. Moreover, about one- 
eighth of the pregnancies ended in abortion or premature labor, and one- 
third of the children going to term were born dead. Such statistics give 
too gloomy a picture, as they are based mostly upon severe cases, and do 
not take into account the milder ones, which are usually not reported. 
Joslin takes a similar view, and considers that many serious cases can be 
carried safely through pregnancy provided that modern anti-diabetic 
treatment is intelligently employed. Furthermore, in several of my 
patients, who had suffered from diabetes for years, the glycosuria dis¬ 
appeared spontaneously during the second half of pregnancy to reappear 
some weeks after delivery. In such cases it might plausibly be assumed 
that the pancreas of the foetus had temporarily compensated for a pan¬ 
creatic deficiency on the part of the mother. 

Leipmann has stated that diabetic women are particularly prone to 
infection at the time of labor, and that gangrenous processes may occur 
in the uterus, in the form of metritis dessicans, just as are sometimes 
noted in other portions of the body in non-pregnant individuals. 

It is interesting to note that 7 of the 26 cases collected by Graefe were 
complicated by hydramnios, and that in five of these sugar could be 
demonstrated in the liquor amnii. According to Rossa, Ludwig, and 
Offergeld, such an occurrence may be regarded as affording presumptive 
evidence that the amniotic fluid is a maternal transudate, since no trace 
of sugar could be detected in the foetal urine. 

On the other hand, too much emphasis cannot be laid upon the fact 
that the mere demonstration of sugar in the urine does not justify the 
diagnosis of diabetes with its serious prognosis. With the ordinary Fehl- 
ing^test, I obtained a distinctive reaction for sugar in about 5 per cent, 
of^all women in the last months of pregnancy. Ordinarily this is doe 





562 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


to lactosuria and is of no clinical significance, but occasionally a true 
glycosuria is present. This occurs about once in 100 or 150 cases, and the 
amount of glucose may vary from *4 to 2 or 3 per cent, without materially 
complicating the prognosis, as the patients suffer no discomfort and are 
safely delivered at term, after which the sugar disappears. Moreover, 
I have seen the condition recur in succeeding pregnancies. 

If more accurate chemical methods be used, sugar can be detected 
much more frequently, and Commandeur and Porcher state that traces 
occur at some time in the course of every pregnancy. They found glucose 
or lactose in 20 and 80 per cent, of their cases, respectively, and occa¬ 
sionally both varieties together. 

Four theories have been advanced to explain the production of this 
variety of glycosuria. Payer and others have shown that pregnant women 
are less tolerant of sugar during pregnancy than at other times, as he 
was able to produce alimentary glycosuria in 80 per cent, of his patients 
by increasing the amount of sugar ingested. Commandeur and Porcher 
hold that the condition is due to the inability of the non-functioning 
breasts to convert glucose into lactose, as normally occurs during lacta¬ 
tion; while Hofbauer believes that it is dependent upon hepatic insuffi¬ 
ciency, which he considers is an exaggeration of the fatty changes at the 
periphery of the liver lobules, which he has described as a concomitant 
of normal pregnancy. Benthin, however, as the result of careful investi¬ 
gation of the sugar content of the blood, is very skeptical concerning the 
part played by hepatic insufficiency, and is inclined to believe that hyper¬ 
glycemia and glycosuria should be attributed to alterations in function 
of some of the ductless glands—the pituitary, according to Wallis and 
Bose. 

Novak, Porges and Strisower in 1913 advanced the view that in 
certain cases the glycosuria of pregnancy is due to increased permeability 
of the kidneys and not to any perversion in the carbohydrate metabolism. 
Kiistner, and Wallis and Bose share this opinion, and the former holds 
that whenever glucose is present in the urine, while the blood sugar 
content is less than 200 milligrams, the condition must be considered as 
renal in origin. They, therefore, conclude that glycosuria of this char¬ 
acter is in no way related to diabetes, but represents a temporary phenom¬ 
enon incident to pregnancy, and Kiistner considers that he has adduced 
experimental evidence that it is in some way associated with the ovarian 
function. 

Due to the frequent occurrence of lactosuria, the first essential, fol¬ 
lowing a positive reaction with Fehling’s solution, is to determine by 
the fermentation test or the polariscope whether lactose or glucose is 
present; if the former, no anxiety need be felt, as lactosuria is a perfectly 
physiological phenomenon. On the other hand, if glucose is present, the 
matter is not so simple, as it is often difficult to determine whether it is 
a manifestation of true diabetes or merely of an alimentary, renal, or 
recurrent glycosuria. 

The former should be diagnosticated if it is found that the condition 
existed prior to pregnancy, or if large amounts of glucose are demon¬ 
strable in the blood, but more particularly if the characteristic symptoms 


DISEASES OF THE KIDNEYS AND URINARY TRACT 


563 


of thirst, emaciation, and dyspnea are present. A probable diagnosis of 
alimentary glycosuria is permissible if the glycosuria disappears upon 
regulation of the diet; while renal glycosuria should be diagnosticated if 
examination of the blood demonstrates the absence of hyperglycemia. 
Occasionally, however, slight glycosuria persists, notwithstanding the 
most rigorous antidiabetic regime; in such cases the patient should be 
carefully watched and the urine examined daily, and the pregnancy 
promptly terminated upon the first appearance of untoward symptoms. 
Fortunately, this has never been necessary in my experience, as the 
patients usually go through pregnancy and labor without difficulty, and 
the glycosuria disappears during the first days of the puerperium. 

Hematuria .—The passage of bloody urine is rarely observed during 
pregnancy, therefore its occurrence should always lead one to suspect and 
search for a serious lesion of the urinary tract. Nevertheless, Chiaventone 
has described an idiopathic hematuria due to pregnancy, and has collected 
18 similar cases from the literature. He considers that the hemorrhage 
is probably due to histological changes in the kidney which result from a 
toxemia. In the absence of a more serious lesion, the bloody urine may 
be due to the presence of varicose veins in the wall of the bladder. 

Pyelitis and Pyelonephrosis .—According to Yinay, attention was first 
called to this complication of pregnancy by Reblaud in 1892. Opitz in 
1905 collected 84 cases, and since then an immense literature has ac¬ 
cumulated upon the subject. 

The disease usually appears in the latter half of pregnancy, when 
the patient, who had previously been well, or had merely complained of 
slight vesical irritation, is suddenly seized with intense paroxysmal pains, 
usually in the right renal region. This is accompanied by a marked ele¬ 
vation of temperature and occasionally by chills, the temperature some¬ 
times running a hectic course. Urinary examination reveals the presence 
of pus cells and bacteria. If the process goes on to the development of a 
pyelonephrosis, palpation shows that the affected kidney is definitely 
enlarged. In this event, the pain may disappear and the kidney become 
suddenly smaller after the passage of a large amount of purulent urine, 
the symptoms reappearing as the kidney fills again. If this condition is 
neglected, the patient may succumb to a septic process. 

Pyelitis results from compression of the uretter at the brim of the 
pelvis by the pregnant uterus, with damming back of the urine, to which 
must be added an infectious process. The latter may be due to an exten¬ 
sion upward from the bladder, or to transmission of bacteria through 
the blood or lymph channels, or from the intestines. Bacillus coli is the 
usual infecting agent, but the streptococcus, gonococcus, or tubercle ba¬ 
cillus is sometimes concerned. Ordinarily pain in one lumbar region, the 
palpation of the enlarged and tender kidney and the characteristic 
urinary findings, as well as the occasional detection of the enlarged and 
sensitive ureter on vaginal examination, should make the diagnosis clear. 
Yet the condition is frequently mistaken for appendicitis and occasionally 
for typhoid fever or salpingitis. 

The treatment consists of rest in bed and an abundant but bland diet, 
together with large quantities of water and milk, and enough sodium 








564 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 






bicarbonate to convert the urinary reaction from acid to alkaline. For 
this purpose 30 grains, administered every four hours, is usually suffi¬ 
cient, but occasionally larger doses may be necessary. In my experience 
better results are obtained in this way than by the use of hexamethyle- 
namin, which was formerly extensively employed. Ordinarily improve¬ 
ment is rapid, but if it does not take place and the condition becomes 
alarming, premature labor should be induced without hesitation, as the 
emptying of the uterus removes the ureteral obstruction and allows of 
free drainage from the kidney into the bladder, the establishment of 
which, as a rule, is followed by complete recovery. Irrigation of the 
bladder, the ureters, or renal pelves is rarely necessary. Occasionally, in 
cases of pyelonephritis, the process may continue after emptying the 
uterus, and necessitate nephrotomy or even removal of the kidney. I see 
each year many patients with pyelitis, and the great majority recover 
spontaneously; occasionally the induction of premature labor is necessary. 
In two neglected cases death occurred from a general septic process, due 
in one instance to the streptococcus, in the other to the gonococcus. 

Floating Kidney. —The symptoms arising from a movable or floating 
kidney are usually considerably alleviated during pregnancy, as the en¬ 
larged uterus tends to retain the organ in its normal situation. In rare 
instances, however, the pedicle of the kidney may become twisted and 
give rise to intense pain, which may be mistaken for renal colic or appen¬ 
dicitis. Careful taxis will usually suffice for reduction, after which the 
symptoms at once disappear. 

Owing to the increased laxity of the abdominal wall following child 
birth, the symptoms are apt to become aggravated when the patient gets 
about, unless she has taken on considerable flesh, so that sufficient fa 
has formed about the kidney to hold it in place. A snugly applied ban¬ 
dage should be worn through the puerperium. 

Dislocation of the Kidney. —Cragin has reported an instance in which 
a congenitally displaced kidney, occupying the pelvic cavity, led to symp¬ 
toms of incarceration, necessitating its removal. He collected five some¬ 
what similar cases, while Stephans collected the literature upon the sub¬ 
ject up to 1912. The condition usually escapes recognition until it gives 
rise to dystocia, but in one of our cases, in which the condition had been 
discovered at a previous laparotomy, the displaced organ was gradually 
pushed out of the pelvic cavity by the enlarging uterus, so that easy 
spontaneous labor occurred. 

Pregnancy After Removal of Kidney. —With the extension of renal 
surgery it is not uncommon to have to consider what may be the out¬ 
come in women who have become pregnant after the removal of one kid¬ 
ney on account of tuberculosis, pyelonephritis or other lesions. Bleynie 
in 1910 collected 35 such cases from the literature, while 11 vears later 

• ’ «7 

Matthews studied 265 labors occurring in 241 nephrectomized women, 
and I see several such cases each year. 

Owing to the fact that the potential renal function is much in excess 
of the needs of the individual, such women do perfectly well provided the 
remaining kidney is normal. On the other hand, if it is the seat of 
chronic nephritis irreparable damage may result from the additional 


- 

I 





DISEASES OF THE NERVOUS SYSTEM 


565 


strain incident to pregnancy; while the development of a toxemia must 
be regarded as much more serious than in a patient with two kidneys. 
Accordingly, in the absence of symptoms, such patients should be care¬ 
fully watched,'and each month accurate chemical and functional tests 
should he made in order to make sure that the single kidney is function¬ 
ing satisfactorily, which is fortunately the case in most instances, when 
spontaneous labor occurs at term. Of the 265 labors reported by Mat¬ 
thews 250 were spontaneous and only two of the patients died. On the 
other hand, if the patient is suffering from chronic nephritis, abortion 
should be induced as soon as the diagnosis is made, and followed by a 
sterilizing operation unless the patient is cooperative enough to make 
intelligent use of contraceptive means. Moreover, premature labor should 
be induced at the first sign of the development of a toxemia. 

Cystitis .—Pregnancy is occasionally complicated by cystitis, which is 
usually due to gonorrheal infection, though the colon bacillus may be the 
‘infective agent. In view of the possibility of an ascending pyelitis and 
a resulting pyelonephritis, the condition demands prompt treatment. 

Floating Spleen.—Occasionally an enlarged spleen occupying the 
lower abdomen may be mistaken for the pregnant uterus. If pregnancy 
supervenes, it is usually uninfluenced by the floating organ, which is 
gradually forced into its normal position as the uterus enlarges. Occa¬ 
sionally, however, pronounced peritonitic symptoms may appear as the 
result of torsion of its pedicle, when splenectomy will be indicated. The 
literature upon the subject up to 1907 has been well reviewed by Heil. 

Diseases of the Nervous System.— Paralysis .—Paralysis of central 
origin sometimes occurs during pregnancy, and is generally associated 
with toxemic or septic processes. Thus, in the toxemias of pregnancy 
and eclampsia, serious disturbances may follow edema of the brain or 
apoplexy. In infectious processes thrombosis may occur in the cerebral 
vessels, and occasionally emboli may cut off the circulation of large areas 
of the brain and lead to various paralyses and even to death. 

Paraplegia of spinal origin occasionally occurs, but, except in rare 
cases of toxemia, is not directly dependent upon the existence of preg¬ 
nancy. It does not appear that spinal paraplegias interfere with con¬ 
ception, as women suffering from them frequently become pregnant. In 
this event, as well as in women with advanced tabes dorsalis, the course 
of pregnancy is usually uncomplicated and the labor easy and compara¬ 
tively painless. 

Neuralgia .—Neuralgic pains are frequent concomitants of pregnancy. 
In rare instances they are very obstinate and resist all treatment, though 
they often disappear spontaneously after labor. During the later months 
of pregnancy the head of the child, after descending into the pelvis, may 
compress one or other sciatic nerve and give rise to severe pain along 
its course, which is sometimes accompanied by intense muscular spasm. 
Owing to its mode of origin, this form of sciatica is not amenable to 
treatment. 

Neuritis. —Whitfield, Eulenberg, and others have directed attention 
to an idiopathic neuritis which occurs during pregnancy. Many cases 
are associated with severe vomiting of pregnancy, and, as the toxemic 








56G 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


origin of the latter lias become recognized, the neuritis is considered as 
a manifestation of the same process, and not as the result of pressure. 
It usually disappears spontaneously, but slowly, after childbirth. The 
affection may be limited to a single nerve, or may appear as a multiple 
neuritis. It is characterized by paralysis of tho affected region associated 
with muscular atrophy and the presence of the characteristic reaction 
of degeneration. There is marked sensitiveness along the course of the 
affected nerves, which is frequently associated with shooting pains. Sen¬ 
sibility of the parts is markedly impaired, and the patients frequently 
suffer from parasthesiae. Occasionally the symptoms are so severe that 
the induction of abortion or premature labor may he justifiable. 

Chorea .—Pregnancy occasionally occurs in choreic individuals, while 
in rare instances the disease does not appear until after conception. In 
the first class of cases it is comparatively unimportant, while in the 
latter the choreic movements are sometimes so intense as to interfere 
with sleeping or the taking of food. In these cases of chorea gravis the 
patient becomes maniacal, and may abort spontaneously. The appear¬ 
ance of fever is of serious import, and at autopsy evidences of malignant 
endocarditis are present. 

Buist has collected 255 cases of chorea complicating pregnancy, with 
a mortality of 17.5 per cent. French and Hicks in 1906 reported 29 
cases which had been observed in Guv's Hospital in the previous thirty 
years, with a mortality of 10 per cent. Many of the cases did well upon 
the usual medicinal treatment. They are skeptical as to the value of 
the induction of premature labor, hut lay great stress upon the serious 
prognostic import of the appearance of fever. The only case of the grave 
variety which I have seen died, in spite of the fact that she fell into 
premature labor spontaneously shortly after entering the hospital. 
Albrecht holds that the condition is usuallv toxemic in origin, and re- 
ports that cure promptly follows the intravenous injection of 20 c.c. of 
blood serum obtained from a normal pregnant woman. 

Epilepsy .—This disease appears to have no effect upon pregnancy, 
though at the time of labor it may be mistaken for eclampsia by inex¬ 
perienced observers. If the attacks are frequent, the patient should be 
put upon large doses of potassium bromid and treated just as at other 
times. As a rule, it is not advisable to allow the mother to nurse her 
child, as lactation sometimes appears to aggravate the disease, while 
serious injury might possibly be done to the child during an attack. 

Hysteria .—Hysteria is a not infrequent complication of pregnancy, 
but does not appear to exert a deleterious influence upon its course. 
Indeed, the physical condition often undergoes marked improvement at 
such times. Occasionally, however, the hysterical symptoms may become 
aggravated. Many authors have of late been inclined to attribute the 
nausea and vomiting of pregnancy to a neurosis, which, in my experi¬ 
ence, is the dominating factor in most cases, but it cannot be regarded 
as the sole cause of the condition. 

Tetany .—In rare instances tetany may occur during the course of 
pregnancy, Meinert, in 1898, being able to collect 20 cases from the 




DISEASES OF THE NERVOUS SYSTEM 


567 


literature. In some patients the disease appears only during pregnancy 
and is absent at other times. H. M. Thomas reported a case in which 
the condition had appeared in 6 successive pregnancies, and gave a full 
resume of the literature up to 1895. 

Formerly tetany was thought to be connected in some way with abnor¬ 
malities of the thyroid gland, as it sometimes occurred after the removal 
of that organ. Following the experimental work of Frommer, Adler and 
Thaler, which was well reviewed by Seitz in 1913, it has been shown 
to be due to the absence or imperfect secretion of the parathyroid bodies; 
as it has been demonstrated that portions of the parathyroids could be 
removed from white rats without effect, but that symptoms of tetany 
would appear whenever the animals became pregnant. 

Kehrer reports that excellent results follow the administration of 
calcium chlorid, just as in non-pregnant persons. 

Goiter .—We have already referred to the slight enlargement which 
the thyroid normally undergoes during pregnancy. Bignami has reported 
a case which, in his opinion, proved that pregnancy occasionally exerts a 
pathological influence upon this gland. During his patient’s first preg¬ 
nancy the thyroid underwent considerable hypertrophy, but returned to 
its normal size after delivery. The condition returned in the second 
pregnancy, the enlargement reaching such proportions that death resulted 
from suffocation. 

While moderate degrees of exophthalmic goiter occur relatively fre¬ 
quently in women, there is but little evidence that pregnancy plays any 
part in its production. On the other hand, the existence of pregnancy 
frequently leads to an exacerbation of the symptoms, which was noted in 
60 per cent, of the 112 cases collected by Seitz, who recorded a fatal 
issue in 7 instances. Serious consequences are to be apprehended espe¬ 
cially when the condition is associated with a persistent thymus, and 
. when death occurs it is usually due to circulatory conditions or to a 
general intoxication. The child is but little affected, although there is 
some evidence to indicate that the tendency toward spontaneous prema¬ 
ture labor is increased. 

Formerly, the induction of premature labor was recommended when¬ 
ever the symptoms became urgent, but with increasing surgical knowl¬ 
edge it has found a formidable competitor in immediate operation upon 
the thyroid. 

In several of my patients the tachycardia was considerably exag¬ 
gerated during the latter part of pregnancy, but became less marked 
after delivery. In none, however, were the symptoms sufficiently urgent 
to justify terminating the pregnancy. 

Apoplexy .—Apoplexy is rarely observed during pregnancy, though it 
is an occasional complication of eclampsia. When it occurs independ¬ 
ently of the latter disease, it is usually the result of emboli due to endo¬ 
carditis, or to phlebitis of the lower extremities. 

Disturbances of Vision .—Disturbances of vision are rarely observed 
during pregnancy, but inquiries should always be made and the patient 
cautioned concerning their diagnostic significance if they appear. 
Amaurosis or total blindness occurring at this time is generally due to 



568 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


albuminuric retinitis, and the first indication of a serious renal affection 
is sometimes afforded by an ophthalmoscopic examination. 

Diseases of the Blood. —Pernicious Anemia .—According to Osier, this 
complication was first described by Channing in 1842. Since then a 
considerable literature has accumulated upon the subject, which is well 
reviewed in the articles of Petersen, and Esch. The disease occasionally 
appears during pregnancy, but most frequently not until after labor. 
It is characterized by marked pallor -and anemia, which are associated 
with weakness and shortness of breath, the extremities also becoming 
edematous. Most recent writers tend to attribute it to a toxic condition 
associated with pregnancy, but no evidence has been adduced concerning 
its nature. 

A positive diagnosis is made by the microscopical examination of the 
blood, when the number of red blood cells is found to be markedly 
diminished. Many of the corpuscles are irregular in shape, while nucle¬ 
ated varieties are not infrequently observed. At the same time there is 
a relative increase in the amount of hemoglobin, though its total amount 
is considerably below normal. As a rule, the disease ends in death if 
not properly treated, and marked fatty degeneration of the various organs 
is found at autopsy. Fowler’s solution should be administered in in¬ 
creasing doses, beginning with 5 drops 3 times a day, and occasionally 
actual transfusion of blood is necessary. 

Leukemia .—^Leukemia is a very rare complication of pregnancy, 
Herman and H. Schroeder being able to collect from the literature only 
8 and 10 examples, respectively. In 4 cases the disease had existed 
before the onset of pregnancy, while in the remainder it appeared after 
its inception. It exerts no direct effect upon gestation, though the asso¬ 
ciation of the two conditions may seriously affect the mother. In several 
instances premature labor resulted, after which the symptoms underwent 
marked amelioration. 

The diagnosis is rendered probable by the existence of marked anemia 
associated with enlargement of the spleen, and is placed beyond doubt by 
a differential blood count. Examination of the foetal blood indicates 
that the characteristic leukocvtes are not transmitted to the foetus. In 
view of the good results which sometimes follow spontaneous premature 
labor, pregnancy may be terminated artificially in serious cases. 

Lead Poisoning. —C. Paul studied the histories of 141 pregnancies 
occurring in women suffering from chronic lead poisoning, and found 
that 86 ended in abortion or premature labor. Moreover, a large num¬ 
ber of the children which were born alive perished at an early period, 
only 10 per cent, remaining alive at the tenth year. There is no doubt 
that the lead is transmitted through the placenta, as in a premature child 
examined by Lewin 16 per cent, of the total weight of the liver was 
due to it. Frongea states that lead poisoning not only leads to abortion 
or premature labor, but is a potent cause of sterility; as in the lead works 
of Sardinia 20 per cent, of the married women are sterile, and an addi¬ 
tional 23 per cent, have only one child. 

Experiments reported by Weller in 1915 indicate that the deleterious 
effect of lead poisoning may be traced to either parent. He found that 




DISEASES OF THE SKIN 


569 


sterility was common when normal female guinea pigs were mated 
with males suffering from chronic lead poisoning, and when pregnancy 
resulted the young were subnormal in weight and exhibited an increased 
mortality after hirth. Likewise, when normal males were united with 
poisoned females, still births occurred very frequently, and the living 
offspring were undersized. In the light of his experiments, Weller be¬ 
lieves that lead exerts a direct unfavorable influence upon the germ 
cells and the early ova. 

Diseases of the Skin.— Impetigo Herpetiformis. —Hebra was the first 
to call attention to the serious nature of this disease, which occurs almost 
exclusively in pregnant or puerperal women, and is characterized by 
superficial pustules, which are arranged in groups or clusters with in¬ 
flammatory bases. New lesions appear on the borders of older and 
crusted confluent patches, while recovery takes place in their centers. 
The lesions occur on the trunk, thighs, and in the neighborhood of the 
genitalia, but rarely upon the face. They are accompanied by itching 
and constitutional symptoms, chills and high fever. The recorded mor¬ 
tality is about 75 per cent., Debreuihl having collected 24 cases with 
18 deaths. The disease, as a rule, does not lead to abortion or premature 
labor, and many of the women affected with it died undelivered. Accord¬ 
ing to Scheuer, it is toxemic and not bacterial in origin. The treatment 
is purely palliative, but in view of the serious prognosis it may be 
advisable to adopt Mayer’s suggestion and inject into a vein small quan¬ 
tities of blood serum obtained from normal pregnant women. 

Herpes Gestationis .—This disease, more frequently known as derma¬ 
titis herpetiformis, is an inflammatory, superficially seated, multiform, 
herpetiform eruption, which is characterized by erythematous, vesicular, 
pustular, and bullous lesions. It occurs occasionally in pregnant women, 
and is accompanied by marked burning and itching. It pursues a chronic 
course, is often attended with fever, and sometimes may even end in 
death. 

Diihring believes that it is probably toxemic in origin, though similar 
lesions sometimes occur during the course of sepsis. In view of its de¬ 
pressing character, the patient should be placed upon tonic treatment, 
while the itching is best allayed by the use of ointments or lotions con¬ 
taining oil of cade, carbolic acid, or similar substances. 

Pruritus .—Itching may occasionally be a distressing complication. 
It may extend over the greater part of the body or be limited to the 
genitalia. General pruritus should be regarded as a neurosis, which is 
probably toxemic in origin. It often gives rise to intense suffering, the 
itching sometimes being so constant that the patient is unable to sleep. 
In some patients the loss of rest and the nervous strain attendant upon 
it exert a marked influence upon the general condition. Such cases are 
best controlled by the administration of sedatives and general tonic treat¬ 
ment. A rigid milk diet is sometimes followed by excellent results. 
When the condition is not amenable to treatment and the patient shows 
objective signs of exhaustion, the termination of pregnancy may be jus¬ 
tifiable. 

Genital pruritus —pruritus vulvae —may be due to several causes, 





570 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


among which are irritating vaginal discharges, parasites or glycosuria. 
When due to the first-named cause, the condition is best treated by the 
administration of astringent vaginal douches and the maintenance of 
absolute cleanliness. At the same time the itching may be allayed by 
the employment of ointments containing cocain, menthol, or carbolic 
acid. Pruritus of diabetic origin is observed but rarely, but the possi¬ 
bility of its occurrence should always be borne in mind and the urine 
examined. If sugar is present, relief can be obtained only by placing 
the patient upon a suitable diet, while at the same time appropriate oint¬ 
ments should be employed. Occasionally intense itching about the anus 
may be due to the presence of seat-worms, which are best destroyed by 
the use of rectal enemata of infusion of quassia. If local measures prove 
ineffectual, a dose of 5 grains of santonin at night, followed by Eochelle 
salts the next morning, will often bring about the desired result. 

Abnormalities of Pigmentation. —During pregnancy abnormalities 
in pigmentation are frequently noted, which are particularly marked 
along the linea alba and about the breasts. In other cases unsightly, 
more or less symmetrical yellowish splotches— cloasma —appear upon the 
face. They are not amenable to treatment, but usually disappear 
promptly after childbirth. 

Hematoma of the Abdominal Walls. —Stoeckel has reported two cases 
of hematoma of the abdominal walls occurring during pregnancy. In 
one case the tumor was situated in the sheath of the right rectus muscle 
just above the symphysis, while in the other it appeared as a large mass 
in the right hypogastric region, and was mistaken for the head of the 
child. The condition resulted from rupture of the inferior and superior 
epigastric artery respectively. 

Relaxation of the Pelvic Joints. —Owing to the great vascularity 
incident to pregnancy, the various pelvic joints always show a somewhat 
increased motility. Occasionally, however, the softening of the inter- 
articular cartilage at the symphysis pubis admits of such abnormal 
motion in the joint as to interfere seriously with the comfort of the 
patient, who suffers from intense dragging pains in the pelvis and lower 
abdomen; while at the same time the gait may be so profoundly altered 
as to suggest the existence of cerebral or spinal trouble. In such cases 
the application jf a tightly fitting bandage about the thighs is followed 
by marked improvement, though occasionally the symptoms are so pro¬ 
nounced that the patient is obliged to take to her bed. The condition 
usually disappears spontaneously during the course of the puerperium, 
but in exceptional instances it may persist and give rise to such great 
discomfort that it may become necessary to “wire” the joint. 

Similar relaxation may involve the sacro-iliac joints and cause great 
suffering. Particular attention has been directed to its frequency and 
significance by Goldthwait and Osgood. In many instances great relief 
may be afforded by applying adhesive strips, which extend outward from 
the posterior surface of the sacrum to the external portion of the 
thighs. 

Accidents during Pregnancy.—The pregnant woman is exposed to 
the same possibility of injury as at other times. Prognosis is not altered 





SURGICAL OPERATIONS DURING PREGNANCY 


571 


except that abortion or premature labor may often occur. Pregnancy 
itself may be complicated by accidents which are incident to that con¬ 
dition, the most important being rupture of an extra-uterine pregnancy, 
rupture of the uterus, and premature separation of the placenta—all 
very serious complications. Their mode of production and treatment 
will be considered in detail in the appropriate chapters. 

Surgical Operations during Pregnancy.—Formerly it was believed 
that the performance of surgical operations during pregnancy would 
almost inevitably bring about abortion or premature labor, even the 
extraction of a tooth being considered a serious procedure. At present, 
however, thanks to anesthesia and a perfected surgical technic, many 
operations can be performed at this time with but little additional risk. 
Accordingly, whenever a condition arises in the pregnant woman which 
imperatively demands surgical treatment, the necessary operation should 
be performed without hesitation. At the same time, if the indication is 
not pressing, it is advisable to defer interference until after delivery, 
so as not to subject the patient to an added strain. 

A review of the literature goes to show that amputations are not more 
dangerous than at other times. I removed one kidney on account of 
a rapidly growing hypernephroma at the end of the fourth month of 
pregnancy, and the patient was delivered spontaneously at term; and 
Schmidt in 1915 collected from the literature thirty-six cases in which 
nephrectomy was performed, and had no effect upon the course of 
pregnancy in twenty-eight instances. Furthermore, numerous cases are 
on record in which paranephritic or broad-ligament abscesses have been 
opened. Tumors of the generative tract can likewise be excised without 
great risk or markedly increasing the danger of premature labor. These 
conditions are considered in the chapter upon the Complication of Preg¬ 
nancy by Diseases and Abnormalities of the Generative Tract. 

Appendicitis .—Appendicitis probably occurs as frequently during 
pregnancy as at other times, but until recently it was usually overlooked. 
Renvall in 1908 recorded 25 personal cases, and collected 253 cases from 
the literature. 

It should be regarded as a very serious complication, as many women 
die if not operated upon, while the surgical procedures undertaken for 
its relief are frequently followed by premature labor. 

Pregnancy does not predispose to its occurrence, but in cases of 
chronic disease, in which the appendix has become adherent to the 
appendages or uterus, exacerbation may result from the traction exerted 
by the enlarging organ. Moreover, when the process has eventuated in 
abscess formation, the rapid decrease in the size of the uterus following 
delivery may readily bring about rupture of the abscess walls. 

The symptoms do not differ from those observed in non-pregnant 
women, but the condition is frequently not recognized, as the pains are 
often considered as being due to the pregnancy itself, while the disten¬ 
tion of the abdominal walls by the enlarged uterus makes difficult the 
appreciation of the rigidity and muscle-spasm, which are usually valu¬ 
able diagnostic aids. 

One should always consider the possibility of appendicitis when a 


572 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


pregnant woman complains of pain in the right side of the abdomen, 
associated with an elevation of temperature and pulse, provided some 
more satisfactory explanation for the condition cannot be found. It 
should, however, be remembered that pyelitis or inflammatory conditions 
of the appendages may give rise to identical symptoms. At the time of 
labor and during the puerperium its recognition is still more difficult, 
and many women have died from perforative peritonitis with the diag¬ 
nosis of puerperal infection. 

Operation is indicated in all cases in the early months, as abortion 
is not likely to occur unless the uterus is subjected to much manipula¬ 
tion. Later in pregnancy the presence of the enlarged uterus renders 
it difficult to expose the parts satisfactorily, and may seriously interfere 
with proper drainage should it prove necessary. In view of this diffi¬ 
culty, it is suggested that the uterus be emptied by cesarean section 
before attacking the appendix. I, however, do not believe that this is 
always necessary, and am convinced that its general adoption will add 
to the gravity of the operation. In the latter months premature labor 
is frequently observed, particularly in cases of abscess formation. It 
may be due to one of several factors—manipulation of the uterus, 
fever, and, when an abscess has formed, to the direct transmission of 
bacteria from it to the foetus. 

Intestinal Obstruction .—This rare complication of pregnancy should 
be treated upon general surgical principles. I have seen two cases. In 
the first intussusception occurred at the site of a tubercular ulcer, and 
death followed resection of the gut; while in the second case obstruction 
was due to constriction by a peritoneal adhesion in a case of tubercular 
peritonitis. This was relieved by operation, and the patient was deliv¬ 
ered at term, but died some weeks later from miliary tuberculosis. 

LITERATURE 

Adler u. Thaler. Exp. und klin. Studien iibar die Graviditats-tetanie. Zeitschr. 
f. Geb. u. Gyn., 1908, 194-223. 

Ahlfeld und Marchand. Ahlfeld’s Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 
239. 

Albrecht. Zur iEtiologie der Chorea gravidarum. Zeitschr. f. Geb. u. Gyn., 1915, 
lxxvi, 677-684. 

Archambaud. Le tetanos pendant la grossesse. La Revue med., 1896, 413. 

Bab. Bakteriologie u. Biologie der kongenitalen Syphilis. Zeitschr. f. Geb. u. 
Gyn., 1907, lx, 161-211. 

Ballantyne and Milligan. A Case of Scarlet Fever in Pregnancy, with Infec¬ 
tion of the Foetus. Trans. Edinburgh Obst. Soc., 1893, xviii, 177. 

Bar et Boull£:. Grippe et puerperalite. L’obstetrique, 1898, iii, 193-214. 
Barnes. On the Thrombosis and Embolia of Lying-in Women. Trans. Lond. 
Obst. Soc., 1863, iv, 30-53. 

Behm. Ueber intrauterine Vaccination. Zeitschr. f. Geb. u. Gyn., 1882, viii, 1-21. 
Benthin. Ueber den Kohlehydratstoffwechsel in der Graviditat, etc. Monats 
schr. f. Geb. u. Gyn., 1913, xxxvii, 305-321. 

Bignami. Tiroidismo e gravidanza. Ref. 1 ’obstetrique, 1896, i, 174. 

Bleynie. De l’avenir des femmes nephreetomisees qui deviennent enceintes 
Th&se de Paris, 1910. 






LITERATURE 


573 


Blot. De la glycosurie physiologique chez les femmes en couches, etc. Comptes 
rendus de l’acad. des sciences, 1856, xliii, 676. 

Boas. Die Wassermann’sche Reaktion. Berlin, II. Aufl., 1914. 

Bollinger. Ueber Menschen- und Thierpocken. Volkmann’s Sammlung klin. 
Vortrage, 1877, Nr. 116. 

Buist. Chorea Gravidarum. Trans. Edinburgh Obst. Soc., 1892, January 12. 

Chiaventone. De 1’hematurie de la grossesse. Annales de gyn. et d’obst., 1901, 
lvi, 196-219. 

Ciiome. Sur un cas de tuberculose congenitale. Arch. mens, d’obst. et de Gvn., 
1918, vii, 294-305. 

Commandeur et Porcher. Recherches sur les sucres urinaires chez la femme 
enciente. Archives gen. de med., 1904, cxciv, 2241 and 2325. 

Cragin. Congenital Pelvic Kidney Obstructing the Parturient Canal. Amer. 
Jour. Obst., 1898, xxxviii, 36-41. 

Dabney and Harris. Report of a Case of Gonorrhoeal Endocarditis in a Patient 
Dying in the Puerperium. Bulletin of the Johns Hopkins Hosp., 1901, xii. 

Debreuihl. Impetigo herpetiformis. Besnier, Brocq et Jacquet, La Pratique 
dermatologique, 1901, ii, 915-920. 

Demelin. Contribution a Uetude des cardiopathies, etc. L ’obstetrique, 1896, i, 
41-57. 

Duncan. On Puerperal Diabetes. Trans. Lond. Obst. Soc., 1882, xxiv, 256-285. 

Edmonds. Malaria and Pregnancy. Brit. Med. Jour., 1899, April 29. 

Esch. Ueber Dauerheilungen und iiber die Aetiologie der perniciosaartigen 
Graviditatsanamie. Zentralbl. f. Gyn., 1921, 341-345. 

Eulenberg. Ueber puerperale Neuritis, etc. Deutsche med. Wochenschr., 1895, 
118-121 and 140-146. 

Fellner. Herz u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 370- 
417 and 497-520. 

Fildes. The Prevalence of Congenital Syphilis Amongst the Newly-born of the 
East End of London. J. Obst. & Gyn. Brit. Emp., 1915, xxvii, 124-137. 

Fiori. Un caso di transmissione di morbillo della madre al feto. Frommel’s 
Jahresbericht, 1900, xiv, 722. 

Fournier. L’heredite sypliilitique. Paris, 1891. 

French and Hicks. Chorea gravidarum. Practitioner, 1906, lxxvii, 178-194. 

Mitral Stenosis and Pregnancy. J. Obst. & Gyn. Brit. Emp., 1906, x, 201-246. 

Friedmann. Exp. Beitrage z. Frage kongenitaler Tuberkelbazilleniibertragung, 
etc. Virchow’s Archiv, 1905, clxxxi, 150-179. 

Frommer. Exp. Versuche zur parathyreoidealen Insuffizienz in Bezug auf Ek- 
lampsie u. Tetanie. Monatsschr. f. Geb. u. Gyn., 1906, xxiv, 748-761. 

Frongea. Quoted by Fritsch, Fruchtabtreibung. Wien u. Leipzig, 1911, p. 58. 

Gast. Experimentelle Beitrage zur Lehre von der Impfung. Schmidt’s Jahr- 
biicher, 1879, clxxxviii, 201. 

Goldsborough. Thrombosis of the Internal Iliac Vein During Pregnancy. Bull. 
Johns Hopkins Hospital, 1904, xv, 193-195. 

Goldthwait and Osgood. A Consideration of the Pelvic Articulations from an 
Anatomical, Pathological and Clinical Standpoint. Boston Med. and Surg. 
Jour., 1905, cliii, 593-601. 

Goth. Ueber den Einfluss der Malariainfektion aut Schwangerschaft, etc. 
Zeitschr. f. Geb. u. Gyn., 1881, vi, 17-34. 

Graefe. Die Einwirkung des Diabetes mellitus, etc. Graefe’s Sammlung zwang- 
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Gu£rard. Herzfehler u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1900, 
xii, 571-577. 


574 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


Harris. Influenza Occurring in Pregnant Women. Jour. Am. Med. Assoc., 1019, 
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Hofbauer. Beitrage zur .ZEtiologie u. Klinik der Graviditats-toxicosen. Zeitschr. 
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Johnston and Morgan. Acute Lobar Pneumonia and Hematogenous Puerperal 
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Joslin. Pregnancy and Diabetes Mellitus. Boston Med. & Surg. J., 1915, clxxiii, 
841-849. 

Kautsky. Schwangerschaft und Mitralstenose. Archiv f. Gyn., 1916, cvi, 121- 
158. 

Kellogg. Chronic Valvular Heart Disease in Pregnancy and Labor. Boston 
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Klotz. Beitrage zur Pathologie der Schwangerschaft. Archiv f. Gyn., 1887, xxix, 
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Knapp. Typhus u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1909, xxx, 
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Kolloch. The Protective Influence of Vaccination, etc. Amer. Jour. Obst., 1889, 
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Kronig. Bakteriologie des Genitalkanales der schwangeren, kreissenden und 
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Lanz. Ueber einen Fall von Tuberculose der Plazenta u. der Eihaute. Archiv f. 
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Lebedeff. Ueber die intrauterine Uebertragbarkeit des Erysipels. Zeitschr. f. 
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Lepileur. Quoted by Bibemont-Dessaignes et Lepage. Precis d’Obstetrique, 
1894, 642. 

Levy. Ueber intrauterine Infection mit Pneumonia crouposa. Archiv f. exp. 
Pathologie, 1896, xxvi, 595. 

Lewin. Ueber die Wirkung des Bleis auf die Gebarmutter. Berliner klin. Woch¬ 
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Liepmann. Diabetes mellitus und Metritis desiccans. Archiv f. Gyn., 1903, lxx, 
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Lomer. Ueber die Bedeutung des Icterus gravidarum, etc. Zeitschr. f. Geb. u. 
Gyn., 1886, xiii, 169-185. 

Masern in der Schwangerschaft. Zentralbl. f. Gyn., 1889, xiii, 826. 

Ludwig. Ein Beitrag zur Pathologie des Fruchtwassers. Zentralbl. f. Gyn., 1895, 
xix, 281-284. 

Lusk. Mitral Stenosis in Pregnancy. Medical News, 1893, lxii, December 1. 

Lvoff. Ptyalismus perniciosus gravidarum. Ref. FrommeUs Jahresbericht. 

Lynch. Placental Transmission, with Report of a Case during Typhoid Fever. 
Johns Hopkins Hospital Reports, 1902, x, 283-322. 

Mackenzie. The Maternal Heart in Pregnancy. Brit. Med. Jour., 1904, ii, 918- 
923. 

Heart Disease and Pregnancy. London, 1921. 





LITERATURE 


575 


Maffucci. Richerclie sperimentale intorno al passaggio del veneno tubcreolare 
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7 

Netter. Transmission intrauterine de la pneumonic, etc. Competes rendus de la 
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Schmidt. Nephrectomy During Pregnancy. Surg. Gyn. & Obst., 1915, xxi, 679. 




576 


ACCIDENTAL COMPLICATIONS DUE TO DISEASE 


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Sperling. Zur Kasuistik der Embolie der Lungenarterie wahrend der Schwanger¬ 
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627-628. 

Whitman and Greene. A Case of Disseminated Miliarv Tuberculosis in a Foetus, 
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lxxxi, 491-559. 

Zweifel, Ueber plotzliche Todesfiille von Schwangeren u. Wochnerinnen. Zen¬ 
tralbl. f. Gyn., 1897, xxi, 1-16. 




CHAPTER XXVI 


* 


THE TOXEMIAS OF PREGNANCY 

Fortunately, in the great majority of cases gestation pursues a 
physiological course and is not attended by untoward symptoms. At 
the same time, there is no other condition in which the border-line 
between health and disease is less sharply marked, since a very slight 
irregularity often suffices to convert a physiological and normal into a 
pathological and abnormal state. 

The general metabolism becomes profoundly modified during gesta¬ 
tion, as is shown by the fact that during its later months the pregnant 
woman stores up nitrogen and water to a far greater extent than at 
other times, so that it would appear that her internal “housekeeping” 
is conducted upon much more economical lines than formerly. Al¬ 
though it is generally held that the excretory functions are more liable 
to serious derangement, since they are called upon to care for the 
elimination of the waste products of the fcetal, as well as of the maternal 
organism, no evidence is available in support of such a view. On the 
contrary, analysis of the urine shows that during the last weeks of 
pregnanacy the woman eliminates less nitrogen than at other times, and 
it has not been demonstrated that the so-called toxemic disturbances of 
pregnancy are primarily dependent upon overworked kidneys, unless 
those organs were insufficient when conception occurred. 

Doubtless, the metabolic changes which characterize normal preg¬ 
nancy and continue for some time after delivery, result from functional 
organic alterations with which we are as yet unfamiliar. Such changes 
are generally attributed to the action of a toxin supposed to be elaborated 
in the maternal or fcetal organism, but as yet no such toxin has been 
identified, and many are even skeptical as to its existence. For this 
reason, it would seem more plausible to attribute them, as well as the 
metabolic changes associated with many of the abnormalities of preg¬ 
nancy, to functional alterations in certain of the endocrine glands, al¬ 
though it must be admitted that at present such views are hypothetical, 
and may be altogether unfounded. 

With increasing knowledge of some of the more usual modifications 
of normal metabolism, the necessity for the accurate control of all the 
factors concerned in such studies has become more fully appreciated, 
and as such control was palpably lacking in certain of the older in¬ 
vestigations concerning the toxemic conditions, it has become necessary 
to disregard the conclusions based upon them. I p to the present, even 
the most careful metabolic studies have done little toward revealing their 

577 



578 


THE TOXEMIAS OF PREGNANCY 


underlying causes, and at best have only served to render untenable 
certain hypotheses which formerly enjoyed a considerable vogue. 

It should always be borne in mind that totally different pathologi¬ 
cal conditions may be accompanied by identical clinical manifestations, 
so that a proper classification cannot be based upon the occurrence of 
such symptoms as albuminuria, fever, coma, or convulsions, but must 
depend upon our ability to isolate certain specific poisonous principles, 
or to demonstrate distinctive pathological lesions. Unfortunately, the 
former is as yet out of the question, but the latter has already been 
accomplished along certain lines. We shall therefore consider separately 
the following groups of “toxemia of pregnancy”: (a) pernicious vomit¬ 
ing; (1)) acute yellow atrophy of the liver; (c) nephritic toxemia; ( d) 
pre-eclamptic toxemia; (c) eclampsia; (/) presumable toxemias. 

PERNICIOUS VOMITING! OF PREGNANCY 

We have already referred to the ordinary type of nausea and vomiting, 
which is noted in the early weeks of gestation. This occurs in approxi¬ 
mately one half of all pregnant women, usually appearing at about the 
sixth week, and disappearing spontaneously six or eight weeks later. 
In such circumstances the patient suffers from nausea, or even vomits 
shortlv after arising, whence the term “morning sickness.” In other 
cases the vomiting occurs at other times and at more frequent intervals, 
and occasionally lasts for a longer period, while exceptionally it con¬ 
tinues throughout the entire pregnancy. 

Ordinarily, such vomiting is attended by no more serious results than 
the actual discomfort connected with it, and many women consider it so 
natural an accompaniment of pregnancy that they do not complain of it. 
Others, however, soon demand relief from the physician, and the mere 
enumeration of some of the many remedies recommended affords con¬ 
clusive evidence that a specific cure has not yet been discovered. In some 
instances the first remedy administered is followed by immediate relief, 
while in other cases various drugs may be employed in succession without 
result. Relief sometimes follows the administration before each meal of 
a capsule consisting of 2 grains of pepsin and V 4 grain nitrate of silver. 
Oxalate of cerium in 5-grain capsules, corpus luteum tablets, dilute tinc¬ 
ture of iodin, dilute hydrocyanic acid, cocain, or bismuth are also recom¬ 
mended. 

In my hands, however, drugs are rarely required, except for the relief 
of constipation, and the condition can usually be cured, or at least greatly 
ameliorated, by suggestion, the adoption of more hygienic methods of 
living, and regulation of the diet. The physician should not make light 
of the condition, but he should impress upon the patient that vomiting 
is not a necessary accompaniment of pregnancy, as is shown by the fact 
that less than one half of all pregnant women suffer from it, and 
furthermore that it can be controlled by exercise of the will, and the 
adoption of suitable hygienic and dietetic measures. He should then 
inquire carefully into her mode of life, and see that proper exercise, oc- 





PERNICIOUS VOMITING OF PREGNANCY 


579 


cupation, amusement, and rest are obtained. The diet should be carefully 
regulated. I lay great stress, particularly on account of its suggestive 
influence, upon the patient eating a hard dry biscuit, such as one uses 
with cheese, the moment she awakens and before raising her head from 
the pillow. Afterwards breakfast may be taken in bed, or not, according 
to her habit. The important point, however, is to arrange that food be 
taken at frequent intervals throughout the day, so that the patient gets 
six small meals instead of three larger ones. It is not sufficient to pre¬ 
scribe this in general terms, but precise directions should be given as to 
exactly what should be eaten at definitely appointed hours. If the 
patient be impressed with the necessity of following these minutiae im¬ 
plicitly, the condition will usually pass off within a few days and the 
employment of drugs will be unnecessary. 

Occasionally, the vomiting becomes more frequent and severe, so that 
in extreme cases no nutriment of any kind, not excepting water, can be 
retained. The condition is then known as pernicious vomiting, which, 
unlike the ordinary morning sickness, is a serious disease, and some¬ 
times leads to a fatal issue, no matter how treated. 

According to Pick, pernicious vomiting occurs about once in every 
thousand pregnant women, but as such statistics are based upon Euro¬ 
pean hospital work they give no clue as to its incidence in private prac¬ 
tice. Among the neurotic women of the upper classes in this country, 
I believe that it is encountered once in every several hundred pregnancies, 
but it appears to be less frequent in England and Germany. 

Etiology.—Since pernicious Amounting is always preceded by the so- 
called morning sickness, and as the latter occurs in approximately every 
other pregnant woman, it may be assumed that the cause of vomiting 
in general must be sought in some factor commonly present in normal 
pregnancy; and, consequently, that pernicious vomiting is due to an 
increase in the amount or in the potency of the same factor, or to de¬ 
creased resistance to its action on the part of the woman. Accordingly, 
its etiology cannot be solved until this “toxic substance” has been dis¬ 
covered, and until it has been ascertained why it becomes increased in 
quantity in certain circumstances. As, unfortunately, neither of these 
criteria have as yet been satisfied, it is evident that whatever may be 
said is largely hypothetical, and may be subject to revision at any 
time. 

In my monograph, which appeared in 1906, I stated that the evi¬ 
dence then available seemed to justify the differentiation of three types 
of serious vomiting, namely, reflex, neurotic and toxemic. I now believe 
that practically every case of vomiting rests upon a toxemic basis, and 
that variations in its course depend upon the severity of the toxemia 
underlying it. In occasional instances, the toxic influence is predomi¬ 
nant, when we have to deal with toxemic vomiting, par-excellence. For¬ 
tunately, however, in the great majority of cases this factor appears to 
act merely as a predisposing cause in neurotic women, and becomes 
negligible after the nervous condition has been overcome. These are 
the cases of neurotic vomiting, which make up the bulk of those we 
are called upon to treat. I have abandoned the conception of reflex 


580 


THE TOXEMIAS OF PREGNANCY 


vomiting, as increased experience has taught me that it should be 
regarded as a subdivision of the neurotic type. In general, it may be 
said that toxemic vomiting is a very serious affection, which frequently 
leads to death; while neurotic vomiting is readily amenable to treatment 
and can usually he cured by suggestive means. 

Matthews Duncan in 1879 pointed out that pernicious vomiting was 
sometimes associated with serious hepatic lesions, but this was not 
generally recognized until the work of Stone, Ewing, and myself showed 
that in many of the fatal cases characteristic lesions were present in 
the liver and kidneys. The former are identical with those occurring in 
acute yellow atrophy. In such cases there is profound necrosis of the cen¬ 
tral portion of the lobules, while the periphery remains intact, and in 
one of my specimens the destruction of tissue was so great that prac¬ 
tically nine-tenths of the organ was thrown out of function (Fig. 459). 
In other cases the necrosis is absent, but the entire liver has undergone 
marked fatty degeneration, so that upon staining fresh sections with 
Sudan red practically the entire specimen seems to be filled with fat. 
Winter, Hofbauer, Ileinrichsdorff, Schickele and others have described 
similar changes. The renal lesions are degenerative in character, and 
are practically limited to the convoluted tubules, whose epithelium in 
many cases is necrotic and whose lumina are filled with debris. As a 
rule, the renal changes occur only in the terminal stages of the disease. 

As the hepatic lesions are altogether different from those observed 
in eclampsia, in which the process begins in the periportal spaces and is 
primarily due to thrombosis, I hold that toxemic vomiting is an entirely 
distinct process, and that it has only three points in common with 
eclampsia, namely, that both occur in pregnant women, are manifesta¬ 
tions of disturbed metabolism and are accompanied by hepatic lesions. 
It should not, however, be believed that the essential process in either 
disease consists in the liver lesions, but rather in the underlying toxemia 
to which they are due. 

The researches of Gpie upon zonal necroses of the liver lend still 
further support to the toxemic basis of vomiting, as he pointed out 
that central and mid zonal necroses are usually the result of systemic 
poisoning. Moreover, it is well known that other poisons which act 
upon the liver—chloroform, arsenic and phosphorus—likewise produce 
cell destruction in these areas, while the peripheral portion of the lobules 
is spared to the last. Additional evidence of the toxemic origin of the 
vomiting is occasionally afforded, in patients who ultimately recover, 
by the development of a polyneuritis, which is associated with char¬ 
acteristic disturbances in sensation, motility and nutrition of the affected 
parts. Such a complication was first described by Whitford, and Job 
in 1911 collected 16 such cases from the literature, while I have observed 
several. On the other hand, it has been argued by several writers that 
the lesions just described may result from starvation alone, but the 
relatively small amount of anatomical material, from which conclusions 
could be drawn, fails to support such a contention. 

In my original article, I pointed out that in toxemic vomiting a high 
ammonia coefficient could be demonstrated in the urine, so that instead 



PERNICIOUS VOMITING OF PREGNANCY 


581 


of 3 or 4 per cent, of the total nitrogen being excreted in the form of 
ammonia, the figure might rise to 10, 20 or even 40 per cent. This I 
at first attributed to such perversion in the intermediary protein met¬ 
abolism, as a result of the hepatic changes, that incompletely oxidized 
substances were excreted in large quantities instead of urea, and I be¬ 
lieved that the existence of a high ammonia coefficient would enable us 
to differentiate between toxemic and neurotic vomiting. This, however. 


F.L.C 



PS. 


Fig. 459. —Liver from Vomiting of Pregnancy Showing Central Necrosis. X 50. 

F. L. C., liver cells showing fatty degeneration; L. C., unchanged liver cells; N., areas of 

necrosis; P. S., portal space. 

was soon shown to be erroneous, as Longridge, Leathes, and others 
pointed out that the high ammonia coefficient was a manifestation of an 
acidosis, while Rand and Underhill considered it an accompaniment of 
inanition and in no way associated with a toxemic process. Finally, in 
1921, Nash and Benedict clearly demonstrated that the urinary ammonia 
is produced in the kidneys as an essential part of the mechanism for 
neutralizing such acids as are brought to them for excretion, thereby 
demonstrating that a high ammonia coefficient gives no information as 
to what is occurring in the liver, and consequently cannot he utilized 







582 


THE TOXEMIAS OF PREGNANCY 


as an index of its metabolism. Were the vomiting woman suffering 
from an acidosis, one might assume that the determination of the 
carbon dioxide combining power of the blood plasma would be diminished 
and thus afford an index of the degree of acidosis, yet the observations 
of Losee and Van Slyke, Emge, and Killian indicate that it shows no 
change, even when the ammonia content of the urine is definitely in¬ 
creased. No explanation has yet been advanced for this seeming para¬ 
dox. 

The belief in the existence of neurotic vomiting cannot be based 
upon anatomical findings, as patients suffering from it rarely die, and 
then only as the result of inanition. Particular attention was directed 
to it by Kaltenbach, who stated in 1891 that the vomiting of pregnancy 
is usually a manifestation of a neurosis, somewhat allied to hysteria, 
and is readily amenable to suggestive treatment. Clinical observation 
affords abundant evidence in favor of such a view, as it is well known 
that many women, who are apparently on the verge of death from 
starvation, suddenly become better spontaneously following a threat 
to induce abortion. Moreover, prompt cure sometimes follows the mere 
administration of an anesthetic, or the employment of the most varied 
and unscientific means of treatment, such as the use of an electrical 
battery which does not function, or the application of leeches to various 
parts of the body, or of medicaments to the cervix. Furthermore, it 
may be safely assumed that the cures following dilatation of the cervix, 
as recommended by Copeman, are in reality due to suggestion. 

Although, as has already been intimated, all types of vomiting in 
pregnant women are primarily dependent upon a “toxic” basis, the 
chief argument in favor of neurotic vomiting is afforded by the sur¬ 
prising regularity with which cure can be effected when suggestive 
means are intelligently employed, as will be described under treatment, 
which would seem to indicate that, once the abnormal neurotic tendency 
has been overcome, the organism can readily cope with the underlying 
toxic factor—whatever it may be. I no longer consider reflex vomiting 
as a distinct type, although every one has occasionally observed serious 
vomiting in women with uterine displacements, ovarian tumors or some 
other lesion of the sexual organs, and has noted immediate relief follow¬ 
ing the replacement of the uterus, the removal of the tumor, or the 
correction of the abnormality. With more extended experience I have 
come to doubt the etiological connection, and now attribute to sugges¬ 
tion most of the cures following the correction or removal of the so- 
called reflex factor. 

Harding and Watson and their associates attribute the nausea and 
vomiting of pregnancy to a lack of glycogen in the liver with subsequent 
fatty degeneration of the organ. They recommend the administration of 
glucose and report very satisfactory results. Analysis of their case 
reports, however, has not convinced me of the accuracy of their claims, 
more particularly as I have obtained equally good results by suggestive 
treatment. Likewise, Titus and his coworkers have employed the 
rapidity with which the organism utilizes glucose administered intra¬ 
venously as a measure of the degree to which the store of glycogen in 


PERNICIOUS VOMITING OF PREGNANCY 


583 


the liver has been depleted. They consider that their work throws con¬ 
siderable light upon the etiology of vomiting by indicating that the 
damaged liver cannot store glycogen, and that the administration of 
glucose is an efficient means of curing the condition. 

Since 1916, J. C. Hirst in repeated communications has advocated 
the view that vomiting of pregnancy is dependent upon deficient corpus 
luteum secretion, and bases his belief upon the fact that at autopsy 
the corpus luteum may be in a cystic condition. He reports satisfactory 
cures following the intramuscular or intravenous administration daily, 
or every second day, of commercial solutions of corpus luteum extract, 
representing one-third or two-thirds of a grain of the dried gland, until 
vomiting ceases or the condition of the patient becomes so serious that 
more radical treatment is imperative. As he admits that the condition 
sometimes proves refractory to such treatment, and as we obtain equally 
good results without its use, I am inclined to attribute to suggestion 
whatever good it may accomplish. 

Symptoms.—Ordinarily, pernicious vomiting begins as the simple 
nausea and vomiting of pregnancy, which gradually becomes so severe 
that nothing can be retained by the stomach. Unfortunately, the mere 
severity of this symptom gives no clue as to whether one has to deal 
with the neurotic or toxemic type. In the former the vomiting may 
continue for weeks, the patient gradually becomes more and more ema¬ 
ciated, and eventuallv dies of starvation if suitable treatment be not 
instituted. 

Toxemic vomiting may occur in either an acute or chronic form. 
In the former the disease pursues a rapid course, and the patient, after 
a few days of ordinary vomiting, may begin to eject coffee-ground vom- 
itus, soon passes into a somnolent or comatose condition, and dies within 
a week or ten days without emaciation. In the latter, and more fre¬ 
quent, variety persistent vomiting may continue for weeks, the patient 
becoming markedly emaciated before the seriousness of the condition is 
appreciated. Later she begins to vomit coffee-ground-like material, 
which she rejects in large quantities and without apparent effort. At 
this time symptoms indicative of toxemia appear, the patient becoming 
torpid or violently excited and passes into a condition of coma, which 
is occasionally accompanied by convulsions. In some instances slight 
jaundice may develop, and, toward the terminal stage of the disease, the 
urine becomes greatly diminished in amount, and contains albumin, 
casts, and even blood. 

Formerly it was taught that in the later stages of the disease fever 
frequently occurred, and was associated with a rapid and thready pulse 
and pronounced albuminuria. This, however, has not been by expe¬ 
rience, as fever was absent in all of my fatal cases. The behavior of 
the pulse is not constant—in some cases it soon becomes rapid and 
thready, while in others it is scarcely accelerated. Several of my patients 
have recovered with a pulse well above 120, while in a fatal case it did 
not exceed 96. For these reasons, I cannot accept Pinard’s dictum that 
abortion should always be induced whenever the pulse rate continues 
higher than 100. 



584 


THE TOXEMIAS OF PREGNANCY 


Diagnosis.—The diagnosis of pernicious vomiting should be made 
whenever the vomiting is constant enough to interfere seriously with the 
nutrition of the patient. The differentiation between the toxemic and 
neurotic types is sometimes difficult, but, as the latter occurs much more 


46 

45 
44 
43 
42 
41 
40 
39 
38 
37 
36 
35 
34 
33 
32 
31 
30 
29 
28 
27 
26 
25 
24 
23 
22 
~^21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
6 
5 
4 
3 
2 
1 
0 

Fig. 460. —Urinary Chart, Neurotic Vomiting. 

In this and the following charts each square cor¬ 
responds to 1 gram of total nitrogen and 1% of 
ammonia nitrogen. Total Nitrogen: Black, 
Ammonia: Red. 


1 2 


































































































































































« 

< 





> 

N 




s 
















Fig. 461. —Urinary Chart, Tox¬ 
emic Vomiting, Recovery 
After Induced Abortion. 
Total Nitrogen: Black, Ammonia: 
Red. 


frequently, the presumption should be in its favor unless isolation and 
suggestive therapy have failed to bring about improvement. Acute 
toxemic vomiting is readily recognized, but from my experience it 

























































































































PERNICIOUS VOMITING OF PREGNANCY 


585 


is impossible by a single clinical examination to diagnosticate the 
chronic variety. Thus, it may happen that two women may appear 
to be equally ill when first seen and to present the same degree of in¬ 
anition, yet careful examination will show that one is suffering from 
neurotic and the other from toxemic vomiting, and the former will re¬ 
cover within a few days after suggestive treatment, while the latter may 
die even after abortion has been induced. For these reasons it is highly 
important that a differential diagnosis be made at the earliest possible 
moment. 

Accordingly, a thorough physical examination should be made, and 
if any serious abnormality of the generative tract be detected, it should 
at once be corrected on the assumption that it may reflexly aggravate 
the symptoms. If no lesion can be detected, the diagnosis lies between 
neurotic and chronic toxemic vomiting, with the probabilities in favor 
of the former. I formerly believed that an ammonia coefficient of 10 
per cent, or higher, justified the latter diagnosis, but as has already been 
indicated this does not hold good; as we now know that a high ammonia 
coefficient may merely be indicative of an acidosis resulting from inani¬ 
tion in neurotic vomiting. Nohvithstanding such limitations, the de¬ 
termination of the ammonia coefficient may be of great diagnostic value, 
but in a negative rather than a positive sense. For example, should it 
fall within the normal limits, we know that no serious perversion of 
metabolism can exist and that pronounced acidosis is absent. In such 
circumstances a diagnosis of neurotic vomiting is justified. On the 
other hand, if the ammonia coefficient is high, we have no means of 
telling whether it indicates a serious pervesion of metabolism or merely 
an inanition acidosis. In this event a diagnosis can be made only by 
observing the course of the disease and by its response to treatment. It 
is a safe working rule to assume that, if improvement does not follow 
five or six days treatment in a hospital, the condition is toxemic in 
origin, and to consider the propriety of emptying the uterus. 

Prognosis.—The prognosis is extremely satisfactory in neurotic 
vomiting, as cure can usually be effected within two or three days by 
suggestive treatment, provided the physician is sufficiently sure of him¬ 
self to be able to impress his belief upon the patient. On the other 
hand, the prognosis is always grave in the toxemic variety, as we have 
no means of determining to what extent the internal lesions have pro¬ 
gressed, or whether it is possible for them to undergo repair, even if the 
underlying cause of the toxemia be removed by terminating the preg¬ 
nancy. In any event, it should be remembered that a certain proportion 
of such cases will die no matter what may be done. 

Pernicious vomiting sometimes recurs, and many women suffer re¬ 
peatedly from the neurotic variety in succeeding pregnancies. Unfor¬ 
tunately this may also occur in the toxemic variety, though the mere 
recurrence of vomiting in a subsequent pregnancy does not necessarily 
indicate that one has to deal with the same type, as I have seen several 
patients who suffered from toxemic vomiting in the first pregnancy, and 
from the neurotic variety in the second (Fig. 462). 





586 


THE TOXEMIAS OF PREGNANCY 


Treatment. —Formerly the treatment of pernicious vomiting was very 
unsatisfactory. This was in great part due to the fact that in the 
neurotic variety cure sometimes occurred when the patient was almost 
in extremis , so that the physician usually deferred inducing abortion in 
the hope that such an outcome might occur in his case. Consequently, 
interference was usually postponed until the patient was so ill that death 
was inevitable, no matter what was done. The recognition, however, of 
the several types of vomiting just described affords valuable information 
as to the treatment to be pursued, and indicates that abortion is usually 


Day of Disease 

32 
30 
28 
20 
24 
22 
20 
18 
16 
14 
12 
10 
8 
6 

Normal 

4 
2 
0 

Gnrnmefl T. N. 
per 1U00 c c 
Urine in o c 

Fig. 462.—Chart Showing Ammonia Coefficient in Two Consecutive Pregnancies 

A, toxemic, and B, neurotic vomiting. 


A. No. 2310 B. No. 2519 



unnecessary in neurotic, and is frequently deferred too long in toxemic 
vomiting. 

When abnormalities of the generative tract are discovered, they 
should be corrected: the displaced uterus should he replaced and held 
in position by a properly fitting pessary, or the ovarian tumor should 
be removed, as the case may he. In the neurotic variety the patient 
should be put to bed and kept from her family as far as possible. 
Preferably, she should be removed to a well regulated hospital and be 
under the charge of an intelligent nurse, as it is only in such circum¬ 
stances that the full effect of suggestive treatment can be promptly 
obtained. She should be assured by the physician that her condition 
is not serious, and will not require active interference. For a day or 
so no attempt should be made to administer nourishment by mouth, but 
large amounts of saline solution or several hundred cubic centimeters 
of 5 per cent, glucose solution should be administered by the Murphy 
drip method every few hours. After a few days’ rest, however, small 
quantities of fluid nourishment should be administered at frequent in- 






































































































































ACUTE YELLOW ATROPHY OF THE LIVER 


587 


tervals, and the patient assured that her condition will pass oft within 
a short time. Ordinarily, if the physician is sure of himself and possesses 
the confidence of the patient, the desired result will usually follow; 
but in exceptional instances more radical treatment is necessary, and 
an absolute rest cure should be insisted upon. 

The existence of an acidosis suggests the advisability of alkaline 
therapy. If properly controlled by frequent determination of the carbon 
dioxide combining power of the plasma, this may do good ; but, in the 
absence of such control, the dosage of sodium bicarbonate should be kept 
within very moderate limits—2 or 3 drams a day—for fear that an 
alkalosis may develop, which in itself may lead to a fatal termination. 
If improvement does not follow these simple means, the physician will 
do well to make a more urgent suggestive appeal to the patient, such 
as lavage after each attack of vomiting, or the subcutaneous injection 
of saline solution under the breasts, preferably with a dull needle. Other 
methods will readily suggest themselves to the experienced physician. 
In such cases the intravenous administration of 250 to 500 c.cm. of 
10 to 20 per cent, glucose solution, repeated four times daily, offers a 
ready means of supplying a certain amount of nutrition. It has no 
specific effect, although Whipple and his associates have shown that 
degenerative changes in the liver are most rapidly regenerated in the 
presence of an abundant supply of carbohydrates. 

We have for years employed this method of treating neurotic vomit¬ 
ing with the greatest possible success, with the result that the induction 
of abortion has become necessary only once in several years, and then 
only when the vomiting was definitely toxemic in origin. I have been 
unable to confirm the claims of Fieux and others that cure frequently 
follows the injection of 10 or 20 c.c. of serum obtained from a normal 
pregnant woman, and I believe that when satisfactory results are obtained 
by such means they should he attributed to the suggestive effect of the 
procedure. 

In the toxemic variety, on the other hand, prompt induction of abor¬ 
tion is the treatment par excellence, and should be performed as soon 
as the diagnosis is made. On account of the possibility of chloroform 
still further damaging the liver, anesthesia should be induced by means 
of ether or nitrous oxid, and the uterus emptied by the most conservative 
method: vaginal hysterotomy if the cervix is rigid, or dilatation by means 
of GoodelFs or HegaFs dilators if it be soft and patulous. Following 
the operation the patient should be given copious saline rectal enemata, 
and for a short time, at least, the administration of food should be 
regarded as a matter of secondary importance. 


ACUTE YELLOW ATROPHY OF THE LIVER 

Acute yellow atrophy of the liver (icterus gravis, typhoid icterus, 
etc.) is an acute and wide-spread antolytic necrosis of the liver cells, 
characterized clinically by jaundice, reduction in the size of the liver, 
and toxic disturbances of cerebration, proceeding to a fatal issue. The 




588 


THE TOXEMIAS OF PREGNANCY 


disease has been observed in both sexes and at all ages, and is a rare 
but very serious complication of pregnancy. Kerkring in 1706 was the 
first to report a fatal case in a pregnant woman, but since then every 
one who has studied the disease has laid stress upon the association. 
Thus, Thierfelder found that 62 per cent, of the 143 cases which he 
collected from the literature had occurred in pregnant women, while 
Quincke placed the incidence at 60 per cent. It is ordinarily observed 
during the second half of pregnancy or early in the puerperium, although 
Beatty and Masson have described cases at the sixth and eighth weeks 
of gestation, respectively. 

Etiology.—Nothing definite can be said concerning its causation, 
although several conditions are known to predispose towards the pro¬ 
duction of the disease. Thus, certain poisons (chloroform, arsenic, 
mercury and phosphorus), and several diseases, such as syphilis, 
septicemia and chronic passive congestion and cirrhosis of the liver, 
are at times associated with lesions, which cannot be distinguished from 
those occurring in the idiopathic form. In the production of this latter, 
and larger group, it is generally assumed that a specific toxin circulating 
in the blood must be concerned. The majority of the cases occurring 
in pregnant women belong in this category, although not a few of the 
recorded cases were probably due to delayed chloroform poisoning. 

Pathology.—In acute yellow atrophy the liver rapidly diminishes in 
weight, which in a comparatively short time may be reduced to less than 
one half of the normal. Its capsule assumes a wrinkled appearance and 
the entire organ becomes softened. On section it varies from dark red 
to almost chrome yellow in color, and upon closer examination each 
lobule is seen to present a reddish center surrounded by a yellowish 
periphery. 

The histological findings vary according to the severity of the dis¬ 
ease. In mild cases the center of each lobule has undergone necrosis 
and the cells of the periphery present an almost normal appearance, while 
between the two is a thicker or thinner zone of cells presenting more 
or less advanced fatty degeneration. In other cases almost the entire 
parenchyma of each lobule is destroyed and is converted into a granular 
mass of necrotic debris, while about the periphery only an occasional 
well-preserved liver cell is seen; at the same time the interlobular spaces i 
with their blood vessels and biliary canals are but little changed. The 
kidneys present signs of acute nephritis and the epithelial cells lining the 
convoluted tubules are in all stages of degeneration, and in extreme cases 1 
are entirely necrotic, while the lumina are filled with casts and debris. 
On the other hand, the glomeruli and the cells lining the collecting 
tubules are but little changed. 

Symptoms.—The symptoms are identical whether the disease occurs 
during pregnancy or the puerperium, and if convulsions appear it is 
usually mistaken for eclampsia. In acute cases the symptoms may come 
on so suddenly as to arouse a suspicion of poisoning, and in some in¬ 
stances the condition has been mistaken for phosphorus or some other 
form of poisoning. Thus it may happen that a woman, who previously 
was in apparently perfect health, may be seized with pains in the abdo- 






ACUTE YELLOW ATROPHY OF THE LIVER 


589 


men, intense headache, and possibly severe vomiting and purging. In 
a short time she becomes torpid or violently delirious and soon passes 
into a condition of coma, which may be disturbed by convulsions. In 
most cases the coma continues for a few hours or days until death super¬ 
venes, but recovery may occasionally occur. There is generally a cer¬ 
tain amount of jaundice, which may vary from a mere discoloration 
of the conjunctivae to pronounced general icterus. The vomited mat¬ 
ter is frequently blood-stained, and sometimes assumes a coffee-ground 
appearance. The urine is diminished in amount, very high-colored, and 
contains albumin, all varieties of casts, and frequently large quantities 
of blood. Fever is usually absent, or the temperature may be even 
subnormal until just before death when it may rise to a high point. The 
pulse and respiration tend to be rapid, and the blood pressure remains 
normal until renal insufficiency develops. Due to the concentration 
of the blood the red blood cells are slightly increased in number, and 
the leukocytes somewhat more so, while the hemoglobin content is di¬ 
minished. In delayed chloroform poisoning the symptoms are verv 
similar, and death usually occurs within the week following the anes¬ 
thesia. Should the patient survive for a longer period, the chances for 
recovery are excellent. 

In other cases the course of the disease is less rapid, and in its 
early stages may simulate an ordinary pre-eclamptic toxemia. Slight 
jaundice, however, soon appears, and the patient gradually becomes more 
and more apathetic and torpid, and eventually passes into a condition of 
coma, which usually terminates in death. In this class of cases the 
diminution in the size of the liver may be traced by percussion, and in 
one of my patients the area of hepatic dullness became diminshed by 
more than one half in the course of a week. If the disease occurs during 
pregnancy, the foetus usually dies as a result of the toxemia, and is 
expelled from the uterus. In such cases, examination of the foetal organs 
may reveal extensive hepatic and renal lesions, and thus aid in estab¬ 
lishing the diagnosis before the death of the mother. When recovery 
ensues, the convalescence is tedious, not so much on account of the 
damage to the liver, which is quickly repaired, but as a result of the 
renal insufficiency. 

Chemical examination of the urine shows changes analogous with 
those already described in toxemic vomiting, and similar to those ob¬ 
served in acute phosphorous poisoning. The total nitrogen is usually 
increased, and its partition always presents marked changes, the urea 
being always diminished and the ammonia coefficient greatly elevated. 
Moreover, there is a marked increase in the amino-acids, and crystals of 
leucin and tyrosin may be demonstrated by appropriate procedures. 
Small quantities of acetone bodies are usually present. 

The blood chemistry has been studied in too few cases to permit any 
general conclusions. In a case studied by Stadie and Van Slyke, the 
urea nitrogen was within normal limits, but the amino-acid nitrogen 
was so increased as to exceed it, while the total non-protein nitrogen 
was not determined. The plasma bicarbonate was at first above normal, 
but gradually fell, reaching 49 volumes per cent, on the day of death. 




590 


THE TOXEMIAS OF PREGNANCY 


It would accordingly appear that a primary alkalosis had been replaced 
by an acidosis as the end approached. Examination of the liver showed 
that it contained three times the normal amount of amino-acids. Such 
variations in the amino-acid metabolism are satisfactorily explained by 
supposing that, as the result of cell destruction, the liver function had 
become so insufficient as to affect the normal mechanism for desaminiz- 
ing the amino-acids and for synthesizing urea. It is generally agreed 
that the increased amino-acid content of the blood results from autol¬ 
ysis of the liver cells, rather than from the absorption of the products 
of intestinal digestion. 

Diagnosis.—The diagnosis can usually be .made from the clinical 
findings and history. Although the occurrence of convulsions may lead 
to a suspicion of eclampsia, the appearance of jaundice should always 
be suggestive, when chemical examination of the blood and urine should 
confirm the diagnosis. When occurring in early pregnancy the condition 
cannot be differentiated from toxemic vomiting, since the lesions, symp¬ 
toms and urinary changes are identical. The prognosis is always bad, 
the possibility of recovery depending upon the extent of the organic 
lesions; and as this cannot be determined during life, one should be 
most cautious in expressing a hope of recovery. 

Treatment. —If the condition occurs during pregnancy, the uterus 
should be emptied as rapidly as is consistent with the safety of the 
patient, and the various excretory organs stimulated, as will be described 
under eclampsia. During the puerperium the latter is the only treatment 
available. Since the work of Whipple and his collaborators, the intra¬ 
venous administration of glucose solutions has been recognized as most 
useful in protecting the liver from further damage and in stimulating 
its repair. For this purpose, 500 cubic centimeters of a 10 or 20 per 
cent, solution may be administered every four hours, and if precautions 
are taken to avoid the production of an alkalosis, sodium bicarbonate 
may be added to the solution. 

NEPHRITIC TOXEMIA 

This condition, as its name implies, is associated with primary lesions 
of the kidneys and is usually noted in women who were suffering from 
chronic nephritis prior to pregnancy, or in whom an acute process origi¬ 
nates during that period. It differs materially from pre-eclamptic tox¬ 
emia, although it frequently happens that final differentiation cannot 
be made until some months after delivery. It occurs relatively frequently, 
and the more closely toxemic patients are studied the more it appears 
that in the past many were diagnosticated as suffering from pre-eclamptic 
toxemia, when in reality the condition was nephritic in origin. 

In my experience, nephritic toxemia is the underlying factor in cer¬ 
tain women who repeatedly give birth to premature infants and present 
a history of being perfectly well up to a certain period of pregnancy, 
when edema and albuminuria suddenly develop. In such cases, the 
urinary symptoms may persist for some months after delivery, but 
eventually disappear, to reappear at about the same period in each sub- 


NEPHRITIC TOXEMIA 


591 


sequent pregnancy. This condition differs markedly from the pre¬ 
eclamptic toxemia, and is explicable by assuming that the individual has 
slightly defective kidneys, which are efficient under ordinary conditions, 
but break down under the strain of pregnancy. 

Etiology. —Many patients present a definite history of having suf¬ 
fered from chronic nephritis before the inception of pregnancy, while 
in others no such history can be elicited. In either event, it must be 
assumed that a toxic influence comes into play, exaggerating in the one 
case the existing renal disease, or bringing it about de novo in the other. 
No information is as yet available concerning its nature or origin, but 
probably the same factors are concerned as in the causation of eclampsia, 
so that the various theories which have been advanced will be discussed 
under that heading. 

Pathology. —Little can be said concerning the pathology of nephritic 
toxemia as accurate information is not available. It must be assumed 
that the kidneys present the lesions characteristic of chronic nephritis, 
to which have been added acute degenerative changes in the convoluted 
tubules. Necrotic changes in the liver are absent. In the more chronic 
forms extensive red and white infarcts usually develop in the placenta, 
and may throw out of function so great a part of it as to interfere with 
the nutrition of the child and lead to its death and premature expulsion. 
Indeed, it may be said that with the exception of syphilis chronic 
nephritis is the most common cause of premature intrauterine death. 

Symptoms.— The condition may appear at any period of pregnancy, 
but is most frequent in its later months. It is usually accompanied by 
lassitude, general malaise, headache, and marked edema, and frequently 
by the ocular symptoms associated with albuminuric retinitis. In other 
cases, however, the patient may complain of little except edema, and 
with the exception of high blood pressure and the urinary changes, which 
will be described below, may appear but slightly sick, yet nevertheless 
she may suddenly pass into a condition of coma which may be accom¬ 
panied by convulsions, and either die or slowly recover. 

Diagnosis. —When symptoms of renal insufficiency develop before the 
child is viable, they are almost invariably due to nephritic toxemia, and 
the earlier the manifestations appear, the more certainly is this true. 
After the seventh month, it is usually impossible to differentiate between 
nephritic and pre-eclamptic toxemia by the ordinary clinical means, so 
that the diagnosis may not be established until several months after 
delivery. In either event, the quantity of urine may be normal or in¬ 
creased, although in pre-eclamptic toxemia oliguria is the rule. Albumin 
and casts are usually present in both conditions, but tend to be more 
abundant in the latter. 

Functional kidney tests are of little value in differential diagnosis, 
although the excretion of phenolsulphonephthalein is more likely to be 
lower in nephritic cases. The blood pressure affords no information, for 
while it may be excessively high, it is occasionally relatively low in both 
conditions. Study of the blood chemistry occasionally offers valuable 
assistance. A high non-protein nitrogen reading speaks in favor of 
nephritic toxemia, particularly if one-half or more of it is made up of 


592 


TIIE TOXEMIAS OF PREGNANCY 


urea nitrogen. On the other hand, a low reading does not necessarily 
indicate its absence. 

With the exception of a history of preexisting chronic nephritis, I 
believe that the most valuable clinical means for differentiating between 
the two conditions consists in the ophthalmoscopic study of the e)e 
grounds. J. P. Miller reported in 1915 that retinal hemorrhage and 
albuminuric retinitis were frequently present in nephritic toxemia, 
but were absent in all cases of pre-eclamptic toxemia or eclampsia which 
he had examined, and when amaurosis was noted in the lattei condition 
that it was due to retinal edema or to deep-seated toxic processes. Fur¬ 
ther experience has only served to confirm these statements, hut at the 
same time it should he remembered that such lesions occur only in a 
fraction of the cases of nephritic toxemia, so that a negative finding 
by no means precludes its existence. Furthermore, the albuminuric ret¬ 
initis may not appear until after the termination of pregnancy. 

If the patient is not seen until after the onset of convulsions the 
condition is usually mistaken for eclampsia, while in the less severe cases 
a diagnosis of pre-eclamptic toxemia is usually made. In many in¬ 
stances the diagnosis becomes clear within the few weeks immediately fol¬ 
lowing delivery, in others several months must elapse, while occasionally 
the true condition of affairs is not recognized for many months or until 
symptoms supervene in a succeeding pregnancy. Generally speaking, it 
may be said that the diagnosis of eclampsia, or pre-eclamptic toxemia 
may be considered assured if the blood pressure falls to normal and all 
trace of albumin and easts disappears from the urine by the end of the 
second or third week after delivery; while the possibility of nephritic 
toxemia should he considered when the urine still contains albumin and 
casts at the end of the month. In such cases the patient should be 
examined at monthly intervals and if traces of albumin and a few casts 
persist the diagnosis of nephritis should be made. Unfortunately, the 
matter is not always so simple, as occasionally patients are discharged 
in apparently excellent condition, with normal blood pressure and urine, 
and yet when examined six months or a year later, present definite signs 
of chronic nephritis. Still less frequently everything seems in order 
until a new pregnancy supervenes, and a few months after its onset the 
old train of symptoms reappears. In this type of case it must be assumed 
that the renal damage is of such low grade that it becomes manifest only 
during pregnancy. 

Prognosis. —Provided convulsions and coma do not appear, the prog¬ 
nosis in nephritic toxemia is good so far as the immediate life of the 
mother is concerned, but in view of the frequency of placental lesions 
the possibility of the premature birth of a dead child should always be 
considered. The ultimate maternal prognosis is bad, as the renal con¬ 
dition tends to become exaccerbated with each pregnancy and to give rise 
to serious symptoms at an earlier period in each successive gestation. 
Consequently, childbirth becomes fraught with serious danger to the 
mother and with progressively poorer chances for the child. 

Treatment. —In the case of a woman seen for the first time, the treat¬ 
ment is identical with that which will be laid down for pre-eclamptic 






PRE-ECLAMPTIC TOXEMIA 


593 


toxemia, while if convulsions or coma occur it is along the same general 
lines as tor eclampsia. After the termination of pregnancy, however, the 
woman and her husband should be made acquainted with the prognosis 
and with the seriousness of repeated pregnancies. Such information as 
is necessary for the prevention of conception should be given, and should 
pregnancy occur in spite of the advice, and serious symptoms supervene, 
the uterus should be emptied by abdominal hysterotomy and steriliza¬ 
tion effected by an operation upon the tubes. 


PRE-ECLAMPTIC TOXEMIA 

This is the most frequent variety of toxemia of pregnancy, and for 
many years was considered as its sole representative. It occurs several 
times in every one hundred pregnancies, and is more frequent in primi- 
gravidae than in women who have borne several children. Fortunately, 
it is usually amenable to treatment, though if neglected, and occasionally 
notwithstanding the most rational prophylactic treatment, it may termi¬ 
nate in eclampsia. 

Symptoms. —Pre-eclamptic toxemia usually appears in the latter part 
of the second half of pregnancy, and occurs but rarely in its early 
months. It should be suspected whenever the patient complains of 
headache, lassitude, or edema, and presents a high blood pressure, but 
particularly if the urine is diminished in amount and contains albumin. 
The symptoms vary from slight malaise to those indicative of profound 
auto-intoxication. In the latter event the patient may complain of severe 
and persistent headache, violent epigastric pain, or visual disturbances 
which may vary from slightly impaired vision to complete amaurosis. In 
many cases the ophthalmoscope shows edema of the retina, but if it is 
absent, the derangement of vision must be attributed to degenerative 
changes in the higher nervous centers. Now and again the patient may 
suffer from hallucinations, and border on the verge of insanity. In rare 
instances the woman may pass into a somnolent condition, which grad¬ 
ually deepens into coma, usually followed by death; but more commonly 
typical eclampsia supervenes. Then the toxemia is pronounced, even 
though it does not eventuate in eclampsia, the child may suffer, and 
not a few cases terminate in the spontaneous expulsion of a dead pre¬ 
mature foetus. The development of edema is associated with a rapid 
increase in the body weight, and Zangemeister has called attention to the 
fact that an abnormally large weekly gain may serve to call attention to 
the onset of a toxemia, before edema or other signs appear. 

The total amount of urine may be greatly diminished, and some¬ 
times falls as low as 200 or 300 cubic centimeters in the twenty-four 
hours. It contains a variable quantity of albumin, casts of all varieties, 
and in severe cases blood cells. Chemical examination has so far given 
no information of value, but that may be due to the fact that as yet no 
acceptable metabolic studies have been made. Conclusions based upon 
the older analyses are valueless, as they were made on incomplete collec¬ 
tions and without regard to the intake of food. 






594 


THE TOXEMIAS OF PREGNANCY 


Likewise, the results of chemical analysis of the blood have as yet 
failed to throw any light upon either diagnosis or prognosis. The inves¬ 
tigations of my former associate, E. D. Plass, show that the total-protein 
nitrogen of the whole blood or of the plasma is usually within normal 
limits at the height of the toxemia, and while the urea nitrogen occa¬ 
sionally constitutes a much smaller fraction of it, he does not agree with 
Killian that this is pathognomonic of the hepatic types of toxemia. The 
uric acid frequently exceeds the normal level of 3.5 milligrams per hun¬ 
dred cubic centimeters, but Slemons and Bogert have found such great 
variations during normal pregnancy and labor that the significance of 
these changes is dubious. Furthermore, it should be remembered that 
the increases noted in these substances are not proportionate to the 
severity of the symptoms; since, as will be pointed out later, the nitro¬ 
genous blood constituents all tend to rise at a rapid rate during early 
convalescence, when they may reach values several times as high as during 
the acme of the disease. Several investigators have reported large rest- 
nitrogen fractions and have attempted to correlate such findings with 
the severity of the symptoms, but Plass found no evidence of such an 
increase. There is usually an increase in the plasma chloride and a 
decrease in the plasma protein, depending upon the extent of the general 
edema. The blood sugar values are usually with the normal range; 
while the serum calcium is low, probably because of the blood dilution. 
The alkaline reserve of the plasma is diminished, but except in rare cases, 
it does not fall below the normal minimum for pregnant women, thereby 
indicating the absence of acidosis. 

Diagnosis.—The clinical differentiation between the nephritic and 
pre-eclamptic types of toxemia is not always easy, and was considered 
in the preceding section. Fortunately, the difficulty in diagnosis is of 
more importance from a scientific than from a practical point of view 
as the treatment to be employed is identical in both cases. As pointed 
out by Goldsborough, conclusions based upon the phenolsulphonephthalein 
kidney function test should be taken with reserve, since in normal preg¬ 
nant women, the output of the dye is sometimes extremely low; whereas 
in toxic patients it may be nearly normal. Complete disappearance of all 
signs and symptoms within two weeks after delivery generally means 
that the condition was pre-eclamptic in type and was not associated with 
permanent lesions in the kidneys. 

Prognosis.—The prognosis in pre-eclamptic toxemia is usually fair, 
but it is entirely dependent upon the amenability of the symptoms to 
treatment. If marked improvement does not occur, particularly if the 
blood pressure remains high and the urine contains large quantities of 
albumin, premature labor should be induced in the hope of preventing 
the onset of eclampsia. On the other hand, even in severe cases the urine 
assumes its normal character within a few days after spontaneous or 
induced labor, while the albuminous content drops to a fraction of a gram 
per liter, and usually entirely disappears before the expiration of the 
second week. If it persists after that period, it is probable that the 
patient is really suffering from nephritic toxemia. Chronic renal disease 
rarely results from pre-eclamptic toxemia, and it is my experience that 



PRE-ECLAMPTIC TOXEMIA 


595 


it is unusual for the latter to recur in succeeding pregnancies. This is 
not a universal rule, but it would appear that one attack confers a 
relative immunity upon the patient, just as in eclampsia. Accordingly, 
when toxemia occurs in repeated pregnancies it may be inferred that it 
is of the nephritic type and is dependent upon the existence of a chronic 
nephritis. 

Treatment. —In the chapter upon the Management of Pregnancy 
attention was directed to the necessity for the frequent and routine ex¬ 
amination of the urine for the purpose of recognizing this condition, 
and of preventing the development of eclampsia by suitable treatment. 
Even in normal cases these examinations should be made once in four 
weeks during the first six months, and every two weeks during the last 
three months of pregnancy. The patient should also be cautioned to 
notify the physician whenever she suffers from headache, disturbance of 
vision, or edema. 

Ordinarily the presence of a trace of albumin may be regarded with 
indifference; but, if a considerable quantity is present, particularly if 
associated with casts, the condition should be regarded as serious, and 
the patient should be kept under close supervision. During this time 
twenty-four hour specimens of urine should be collected and note made 
of its total quantity, as well as of the amount of albumin present. More¬ 
over, the blood pressure should be frequently taken and attention paid 
to changes in the subjective symptoms. The sudden appearance of 
amaurosis or of blurring of the vision and more particularly of pain in 
the epigastrium, should always be regarded with suspicion, as they are 
frequently precursors of eclampsia. The same may be said of a sudden 
increase in the blood pressure, which occasionally exceeds 200 milli¬ 
meters. 

The best indices of the patient’s condition are the blood pressure 
and quantity of albumin. Any rise in the blood pressure above the 130 
mm., which cannot be explained by temporary disturbances, should lead 
to more careful observation of the patient. There is little occasion for 
alarm when the pressure is below 150 or 160, but higher readings indi¬ 
cate danger of serious toxic manifestations. By testing the urine with 
Esbach’s reagent in a specially constructed albuminometer (Fig. 463), 
the albumin content per liter, as well as the daily output, can be deter¬ 
mined with sufficient accuracy for clinical purposes. The total daily 
output probably gives more reliable information, if it is certain that all 
the urine has been saved, but the content expressed in grams of albumin 
per liter of urine is also of great prognostic value. It should, however, 
always be remembered that the latter reading may vary considerably with 
alterations in the output of urine, whereas the daily quantity remains 
remarkably constant. Generally speaking, it may be said that an excre¬ 
tion of more than one gram of albumin per liter or of a total of more 
than three grams in twenty-four hours is indicative of a serious condition. 

In mild cases the patient should be put to bed, or at least confined 
to her room and placed upon a restricted diet, meats and the coarser 
vegetables being interdicted; or, better still, for a while she should 
depend solely upon milk, which is an excellent food, as well as efficient 


596 


THE TOXEMIAS OF PREGNANCY 




diuretic. At least two, preferably three, quarts should be consumed in 
the twenty-four hours. To relieve the monotony, she may be allowed 
small quantities of lettuce salad, bread and butter, and occasionally a 
little herring roe as a relish. She should also be made to take large 
quantities of fluid in the shape of plain water, lithia water, or cream of 
tartar lemonade (1 dram to the pint). 

In most cases such treatment will be followed by a marked ameliora¬ 
tion of the symptoms, an increased urinary secretion, a decrease in the 

amount of albumin, a fall in blood pressure, and a 
prompt return to normal conditions. If the desired 
result is not promptly obtained, a brisk purge of 
Rochelle or Epsom salts should he given. Hot packs 
or sweat baths were formerlv advocated, but are now 
little used, as it has been realized that they only 
cause the elimination of water, which in all prob¬ 
ability has been stored in the tissues as a protective 
mechanism. If under treatment the symptoms dis¬ 
appear, the albumin becomes less and the hlood pres¬ 
sure falls, the outlook may he considered excellent. 
On the other hand, if the albumin steadily increases 
in amount, while the subjective condition of the pa¬ 
tient remains unchanged or becomes more serious, 
the prognosis is ominous, and the onset of eclampsia 
can probably be avoided only by emptying the uterus, 
no matter what be the period of pregnancy. In my 
experience, the continued daily output of over 5 
grams of albumin per liter, or a blood pressure which 
persists in the neighborhood of 200 millimeters, 
irrespective of other symptoms, justifies interference. 

Before the induction of labor is resorted to, vene¬ 
section should be employed. The removal of 500 to 
1,000 cubic centimeters of blood frequently leads to 
a prompt amelioration of the symptoms, the hlood 
pressure falling and the output of urine increasing, 
while the subjective symptoms are largely relieved. As a rule this effect 
is only transitory, but exceptionally it leads to permanent improvement, 
just as happens after the completion of labor, and the pregnancy con¬ 
tinues as if nothing had happened. 

Induction of labor is the last resort, and should be regarded as a 
confession that our therapeutic resources have failed. If haste is not 
essential, this is easiest effected by the introduction of a bougie, but if 
the indications are urgent the uterus should be emptied by vaginal hyster¬ 
otomy, unless the cervix be so soft, and its canal so obliterated, that 
manual dilatation by Harris’s method can be safely effected. 

Unfortunately, we are not yet acquainted with the actual toxic agent 
or agents concerned in the production of this particular variety of 
toxemia, and consequently the indications for interference are only rela¬ 
tive. Thus, it sometimes happens that the urinary findings and clinical 
symrptoms so improve under treatment that one is inclined to feel that 



Fig. 463.—Esbach’s 
Albuminometer. 













ECLAMPSIA 


597 


all danger has passed, nevertheless eclampsia suddenly supervenes. On 
the other hand, one occasionally feels that the induction of labor is 
imperatively demanded, but after deferring it for some reason, the 
patient may unexpectedly make a satisfactory recovery without any un¬ 
toward manifestation. Such experiences indicate that our knowledge 
of the subject is far from complete; but at present all that is possible 
is to follow the directions just given, and to interfere whenever the 
urinary findings and clinical symptoms indicate that the condition is 
serious. By so doing, it is possible that premature labor may occasionally 
be induced unnecessarily; but, on the other hand, many more patients 
will be saved from the dangers of eclampsia, as the prompt recognition 
and conscientious treatment of pre-eclamptic toxemia constitutes our 
only available means of preventing that dreaded disease. 

Some authorities go so far as to hold that such prophylaxis is abso¬ 
lute, and that the occurrence of eclampsia indicates neglect on the part 
of the physician. No doubt this is usually the case, but the rule is not 
without exception; as upon several occasions I have seen eclampsia occur 
in women, whose urine had been negative only the day before the out¬ 
break of convulsions. 

ECLAMPSIA 


Eclampsia is an acute toxemia occurring in the pregnant, parturient, 
or puerperal women, and is usually accompanied by clonic and tonic 
convulsions, during which there is loss of consciousness followed by 
more or less prolonged coma, and frequently results in death. Generally, 
convulsions and eclampsia are considered as synonymous terms, but such 
a view is not correct, inasmuch as a number of well-authenticated cases 
of eclampsia without convulsions are recorded, and, moreover, other 
toxemic conditions occasionally occur in obstetrical practice which are 
likewise accompanied by convulsions or coma. Accordingly, the only 
absolute characteristic feature of the disease is the presence at autopsy of 
the hepatic lesions which will be described later. 

Frequency. —Statistical studies indicate that eclampsia occurs about 
once in every 500 labors, but it is almost impossible to determine its 
incidence with any degree of exactness, inasmuch as few practitioners see 
a sufficiently comprehensive series of cases in private practice to permit 
of trustworthy conclusions, while, on the other hand, hospital records 
by themselves give an exaggerated idea of its frequency, for the reason 
that many of the patients would have remained at home had they not 
had convulsions. 

The following table would indicate that eclampsia occurs in less than 
1.0 per cent, of the women entering lying-in hospitals. 


Goldberg (Dresden, 1891) in 
Oassamayor (Paris, 1892) 

Veit (Germany, 1906) 

Knapp (Prague, 1900) 

Newell (Boston, 1900) 
Reinburg (Paris, 1905) 
Lichtenstein (Leipzig, 1911) 
Williams (Baltimore, 1912) 
McPherson (New York) 


10,717 labors, 

81 cases 

i of eclampsia 

(0.75%) 

16,225 “ 

99 

< < 

C ( 

(0.61%) 

149,366 “ 

905 

i < 

i c 

(0.61%) 

7,636 “ 

41 

( ( 

(( 

(0.53%) 

6,700 “ 

99 

(( 

(( 

(1.48%) 

26,511 “ 

90 

i < 

u 

(0.34%) 

14,836 “ 

400 

( ( 

< i 

(2.68%) 

11,000 “ 

110 

i ( 

( i 

(1.0%) 

120,000 “ 

890 

< ( 

( ( 

(0.75%) 


598 


THE TOXEMIAS OF PREGNANCY 


In other words, 2,715 cases occurred in 362,991 labors, an incidence 
of 0.75 per cent. These statistics include all cases of eclampsia, but 
when Lichtenstein differentiated between the total number of cases and 
those who were in the hospital at the onset of the disorder, he found that 
in the latter the incidence was only 1 to 600. 

Eclampsia varies markedly in frequency at different times, Cassa- 
mayor stating that in Tarnier’s clinic in Paris it was observed many times 
more frequently in some years than in others. In my experience it often 
happens that months elapse without the occurrence of a single case, when 
suddenly a number are observed in quick succession. Such observations 
have led various writers to discuss the probability of the disease being 
of infectious origin, but convincing evidence in favor of such a view has 
not been adduced. Harrar has shown graphically the monthly variations 
at the New York Lying-in Hospital during a period of ten years (Fig. 
464), and considers that the increased incidence in early spring is due 
to the cold damp weather prevailing at that time. Furthermore, it is 
generally accepted as true that eclampsia occurs less commonly in warm 
climates, as well as among those whose diet is largely vegetable in char¬ 
acter. During the World War, a decided decrease in its incidence was 
noted in Central Europe, and many writers have attempted to explain 
the fact by invoking the change in dietary customs made necessary by 
the food blockade. 

Clinical History.—Eclampsia occurs almost exclusively in the second 
half of pregnancy and becomes more frequent the nearer term is ap¬ 
proached, while in about one-fifth of the cases the first convulsion does 
not appear until after the completion of labor. Zweifel has reported a 
case occurring as early as the third month, while a number of writers 
have reported cases occurring late in the puerperium. Generally speak¬ 
ing, however, reports of eclampsia appearing more than twenty-four hours 
after delivery should be regarded with skepticism, as careful investiga¬ 
tion will usually indicate that the convulsions are of some other origin. 

Primiparity, multiple pregnancy and hydramnios are important pre¬ 
disposing factors and it is generally admitted that two-thirds of all 
cases and upwards occur in primiparous women. Moreover, the disease 
is noted proportionately six times more frequently in twin than in single 
pregnancies, and four or five times more frequently when the pregnancy 
is complicated by hydramnios. 

Eclampsia may occur during the course of advanced extra-uterine 
pregnancy, and Maygrier observed a case in the false labor accompany¬ 
ing that condition. Falk, Sitzenfrey and others have reported cases 
occurring in association with hvdatidiform mole, and I have observed 
a case of profound pre-eclamptic toxemia complicating the same ab¬ 
normality, and in the appropriate section an illustration will show 
the uterine cavity completely distended by the mole. The possibility 
of such an occurrence has been urged as evidence that the metabolism 
of the foetus plays no part in the etiology of eclampsia. 

An eclamptic convulsion sometimes occurs without warning, “like a 
bolt from a clear sky,” in women who were apparently in perfect health. 
In the vast majority of cases, however, the outbreak is preceded for a 


ECLAMPSIA 


599 


longer or shorter period by premonitory symptoms indicative of pre¬ 
eclamptic toxemia, which was lacking in only 15 per cent, of the 2,005 
cases analyzed by Eden in 1922. The attack may come on at any time, 
sometimes while the patient is sleeping. If she is awake, the first sign 
of the impending convulsion is a fixed expression of the eyes, which 
soon begin to roll from side to side. The pupils are usually dilated, 
less often contracted. The convulsive movements appear first about the 
mouth, which begins to twitch and is drawn to one side, the entire face 
becoming distorted. They extend rapidly to the arms, the body, and, 
finally, to the legs. They are usually clonic in character, though some¬ 
times they take on a tonic form and the patient becomes rigid. The 



Fig. 464. —Graphic Chart Showing the Incidence of Eclampsia in the Various 
Months as Determined from the Records of the New York Lying-in Hospital 
(Harrar). 

(The line shows the number of cases per 100 deliveries). 


breathing is stertorous, the face congested and flushed, the patient foams 
at the mouth, and often bites her tongue. During the convulsion, which 
may last for a few seconds to two minutes, the woman is profoundly 
unconscious, and after the movements cease passes into a condition of 
coma which lasts for a longer or shorter period. 

More particularly when the disorder appears in the latter part of 
labor or during the puerperium, a single convulsion only may be ob¬ 
served. Oftener, however, the first is the forerunner of other convul¬ 
sions, which may vary in number from 1 or 2 in mild, to 10 or 20 or 
even 100 or more in severe cases, the intervals between them becoming 
shorter in inverse proportion to the number. In rare instances they 
follow one another so rapidly that the patient appears to be in a pro¬ 
longed, almost continuous, convulsion. 

The duration of the coma is very variable. When the convulsions 









600 


THE TOXEMIAS OF PREGNANCY 


are infrequent, the patient usually recovers consciousness after each 
attack, while in severe cases the coma persists from one convulsion to 
another, and death may result .without any awakening from it. In 
rare instances a single convulsion may be followed by profound coma, 
from which the patient never emerges, though, as a rule, death does not 
occur until after a frequent repetition of the convulsive attacks. The 
immediate cause of death is usually edema of the lungs or apoplexy, 
though if the fatal issue is postponed for several days, it is usually 
attributable to aspiration pneumonia or puerperal infection. 

In most cases during the seizure the arterial pressure is markedly 
increased, and may reach well over 200 mm., while the pulse is full and 
bounding. In severe cases, however, it is weaker and more rapid, becom¬ 
ing more compressible and filiform with each succeeding convulsion. 
The temperature usually remains normal, but occasionally it rises to 
a very considerable height from the onset of the disease. An elevation 
to 104 or 105 degrees is not unusual, and in one of my fatal cases the 
temperature reached 109.5 degrees just before the end. This complica¬ 
tion is of very serious prognostic import; although, if the patient does 
not die, the temperature usually falls to normal within twenty-four 
hours after the cessation of the eclamptic seizure. As regards the cause 
of this elevation there is much discrepancy of opinion. Olshausen be¬ 
lieved that the poison which causes the eclampsia also stimulates the 
thermal centers, while Zweifel holds that the fever is of infectious 
origin. I incline to the former view, for the reason that in all cases, 
which I have investigated, bacteriological examination of the uterine 
lochia gave negative results. On the other hand, if the fever persists 
for any great length of time after the convulsions have ceased, it is 
practically always a manifestation of puerperal infection, as women 
suffering from the disease appear to be especially susceptible to bacterial 
invasion. 

While the convulsions are by far the most striking clinical manifesta¬ 
tions of eclampsia, and even give the disease its name, instances are 
occasionally met with in which they are absent, the patients dying in 
coma and presenting at autopsy the hepatic and renal lesions charac¬ 
teristic of the affection. Three such cases were reported by Schmorl in 
1902. I have seen several, two of which were recorded by Slemons in 
1907. Since then the condition has been more generally recognized, 
and was considered critically by Schmid in 1911, and by Schickele in 
1917. In many instances the absence of convulsive attacks has led to an 
erroneous clinical diagnosis, the condition having been regarded as 
uremic coma, phosphorus poisoning, fulminating bacterial infection, 
WeiFs disease, or acute yellow atrophy of the liver. In fact, a correct 
diagnosis can usually be established only at autopsy. 

According as the disorder first appears before or during labor or in 
the first hours of the puerperium, it is designated as antepartum, intra¬ 
partum, or postpartum eclampsia. It is generally stated in the text¬ 
books that the last is the least common; but that the conclusions as to 
the relative incidence of the different varieties are by no means unani¬ 
mous is shown by the following table: 


ECLAMPSIA 


601 


Antepartum Intrapartum. Postpartum. 


Olshausen. 40 % 46 % 14 % 

Knapp. 24.5% 60.9% 14.6% 

Goldberg. 26 % 57 % 17 % 

Eeinburg. 49.5% 29.5% 20 % 

Lichtenstein. 21 % 61.5% 17.5% 

Williams. 55 % 22 % 23 % 

Eden. 61.5% 19.2% 19.3% 

McPherson. 56 % 9.6% 34.3% 


It would appear from the statistics just cited that postpartum 
eclampsia constitutes about one-fifth of the entire number of cases, 
while the statements as to the incidence of the antepartum and intra¬ 
partum varieties are not so unanimous. Eden and I hold that the former 
occurs much more frequently—an opinion which was shared by Ols¬ 
hausen, who considered that the contrary statements are due to the 
fact that most writers have failed to remember that eclampsia usually 
supervenes before the estimated end of pregnancy and that uterine con¬ 
tractions often set in with the first convulsion, so that if the patient 
is not seen before the seizure it is often difficult to determine with which 
variety one has to deal. 

Antepartum eclampsia may terminate in several ways. As a rule, 
labor sets in and a premature child is born spontaneously, or the uterus 
is emptied by operative procedures. Sometimes the patient dies unde¬ 
livered. Lichtenstein has directed particular attention to the fact that 
labor does not always supervene, but that the woman may recover from 
the attack and give birth to a dead or macerated foetus some time after¬ 
wards, or may even go on to term and bear a living child. In 1911 he 
collected from the literature 56 examples of the former and 64 of the 
latter eventuality, and has pointed out that, while the death of the child 
in the first instance may account for the cure of the disease, such an 
explanation will not hold in the second instance, and renders it very 
questionable whether the life or death of the child has anything to do 
with its causation. Olshausen and others have described as recurrent 
eclampsia cases in which the patients, after being perfectly well for a 
longer or shorter period, have a recurrence of the seizure, which may 
terminate in any one of the ways mentioned above. 

If the attack occurs during labor, the pains usually increase in fre¬ 
quency and severity, so that the child will be born somewhat sooner 
than usual, after which the convulsions generally cease. On the other 
hand, in severe cases, or when there is some impediment causing dystocia, 
the patient may die undelivered, unless operative measures are under¬ 
taken. 

In postpartum eclampsia the attack usually comes on soon after 
delivery, and recovery often occurs after a single convulsion. In other 
cases, however, the seizures follow one another in rapid succession, and 
frequently cause death. The general belief that cases of this variety are 
comparatively benign is denied by Olshausen and Lichtenstein, who 
noted a mortality of 25 and 27 per cent., respectively. 

A few instances have been reported in which convulsions did not ap¬ 
pear until several weeks after the birth of the child. It can be safely 
assumed, as was pointed out by Van de Velde, that such conditions 










602 


THE TOXEMIAS OF PREGNANCY 


were not eclamptic at all, but were due to hysteria, uremia, or other 
causes. 

Occasionally the onset is preceded by a distinct aura, but this is 
usually lacking. In rare instances the convulsion comes on without 
warning, but it is generally preceded for some days or even weeks by 
symptoms indicative of pre-eclamptic toxemia. As has been pointed out 
by Olshausen, severe epigastric pain, or a sensation as if the thorax were 
encircled by a tight girdle, is a frequent precursor of the seizure, and 
is a sign to which too much attention can hardly be paid. 

The convulsions are always followed by unconsciousness. Moreover, 
the patient may not only not remember the attack itself, but even have 
no recollection of occurrences which had taken place several hours pre¬ 
vious to it. This is a not altogether uncommon observation, and may 
sometimes have an important bearing from a medico-legal point of 
view. In a small proportion of cases eclampsia is followed by marked 
mental derangement, and it must not be forgotten that such psychoses 
constitute one of the well-recognized varieties of puerperal insanity; but 
whether it is a direct result of the disease or is due to a coincident 
infection has not vet been demonstrated. 

In rare instances, as the result of cerebral lesions incident to eclamp¬ 
sia, a hemianopsia may develop during the puerperium. A case of this 
character, occurring in one of my patients, was reported in detail by 
Woods at the 1902 meeting of the American Ophthalmological Society. 
More frequently disturbed vision during the latter part of pregnancy 
is due to edema of the retina, which usually disappears spontaneously. 
Occasionally, hemorrhagic retinitis is observed, but in other cases the 
visual disturbance is unattended by demonstrable changes in the retina 
or optic nerve, and is to be regarded as a manifestation of the general 
toxemia, complete recovery usually following within a few days after 
the termination of pregnancy. As was indicated in the section on 
nephritic toxemia, aluminuric retinitis is a complication of chronic 
nephritis, but not of pre-eclamptic toxemia or eclampsia. Accordingly, 
the outcome is dependent upon the further course of the underlying 
disease. 

In a small number of cases the patient becomes markedly jaundiced, 
either during or shortly after the convulsive seizure. This sign is of 
grave prognostic significance, indicates serious hepatic involvement, and 
should lead one to suspect the possible existence of acute yellow atrophy 
of the liver. At the same time, it is well to remember that the icterus 
may be due to causes not associated with the pregnant state. 

The urine during the eclamptic seizure usually gives evidence of a 
marked renal insufficiency. It is invariably diminished in amount and 
frequently almost entirely suppressed. On microscopical examination 
various types of casts are found in great abundance, although the hyaline 
and granular varieties predominate. Epithelial casts also occur, as 
well as isolated renal cells, while blood is nearly always present. Hemo¬ 
globinuria may also be observed. 

Albuminuria is almost constantly present, and frequently is so pro¬ 
nounced that it is necessary to dilute the urine to several times its bulk 


ECLAMPSIA 


603 


before an accurate determination can be made by means of the Esbach 
tube. In the majority of my cases this test showed the presence of at 
least 10 grams of albumin per liter (one per cent.) during the acute 
stage of the disease, while in many instances much larger quantities were 
noted—sometimes as high as 30 or 40 grams. The albuminous preci¬ 
pitate is composed of both serum albumin and serum globulin, and in 
one instance, in which the relative amounts of each were determined, the 
latter was found to be 34 per cent. Wallis states that in eclampsia the 
ration is 2 to 1, while in nephritis it is 6 to 1. 

This high percentage output of albumin is only temporary, although 
the total daily excretion may remain high for some days. This is in 
part due to the fact that as recovery occurs the oliguria becomes re¬ 
placed by a polyuria, so that the same quantity of albumin in the 
greatly increased bulk of urine leads to a marked lowering of the Esbach 
readings. Usually it falls to a fraction of one gram per liter within 
36 or 48 hours after delivery, and completely disappears in the course 
of two or three weeks. This rapid decrease was carefully studied by 
Emerson in one of my patients, specimens being taken at the time of 
convulsions, and at four-hour intervals during convalescence. During 
the eclamptic attack the urine contained 1.23 per cent, of albumin by 
weight, as compared with 0.25 per cent, twelve hours later. Whether it 
is better to consider the percentage or the total daily output of albumin 
is not yet clear. In my experience the former seems of greater prog¬ 
nostic value, while, on the other hand, it might well be urged that a 
considerable total daily output gives a more accurate conception of the 
extent of depletion of the proteins of the plasma, which are apparently 
so essential. It is interesting to note that these high grades of al¬ 
buminuria do not necessarily indicate profound renal lesions, as in many 
of my cases, in which the urine also contained large quantities of casts, 
only a mild degenerative nephritis was found at autopsy. 

There are no very significant alterations in the known chemical con¬ 
stituents of the urine, which cannot be well accounted for by the changes 
in the metabolic condition of the patient. As a result of the oliguria 
the total nitrogen output is low, and, consequently, the urea nitrogen 
output is proportionately diminished, while the twenty-four hour out¬ 
put of uric acid, creatinine, etc. is within normal limits. Both the 
actual and relative output of ammonia is diminished during the attacks, 
but if recovery ensues, this is soon followed by a moderate rise, which 
persists for a variable period. These figures were not obtained in ob¬ 
servation which were above criticism, but their frequent repetition leads 
us to believe they are correct. In our experience such a rise should be 
regarded as favorable, as in several fatal cases the ammonia remained 
consistently low. Similar observations were made by Landsberg in 1913, 
but their significance is not clear, and definite statements cannot be 
made until metabolic studies are available, which are much more 
elaborate than any which have yet been recorded. The output of 
chlorides is unusually low during the attack, to be followed by a pro¬ 
nounced rise during the first days of convalescence, after which normal 
conditions become restored. 




604 


THE TOXEMIAS OF PREGNANCY 


During convalescence the urine promptly returns to a normal con¬ 
dition, but at the same time the increase in its quantity and nitrogenous 
content cannot be regarded as being entirely due to the elimination of 
materials, whose retention was supposed to have caused the disease. 
We now know that somewhat similar changes are observed after normal 
labor, when the high nitrogen content must be accounted for by the 
involution of the uterus and other puerperal changes. Although the 
albumin usually clears up rapidly, it frequently shows a slight increase 
when the patient is allowed a more liberal diet. Oh the other hand, its 
persistence for longer than a month indicates the existence of a chronic 
nephritis, which in most cases antedated the eclamptic attack, but occa¬ 
sionally appears to have resulted from it. 

Within the past few years a great amount of chemical work has been 
done upon the various constituents of the blood, in the hope that altera¬ 
tions in their concentration would throw light upon the nature of the 
toxemic process, but as yet little helpful information has been 
obtained, although such investigations have served to discredit certain 
theories formerly in vogue. At present it must be admitted that chemical 
study of the blood is of little assistance from either the diagnostic or 
prognostic point of view. While certain authors claim that a distortion 
in the ratio between the quantity of nitrogen contained in the urea and 
the total quantity of non-protein nitrogen enables them to differentiate 
between “renal” and “hepatic” eclampsia, our extended experience in¬ 
dicates that such changes are not pathognomonic. Occasionally at the 
time of the attack a slight retention of the various non-protein nitrog¬ 
enous constituents may be demonstrated; while in other cases they 
are present in normal amounts. In accordance with the usual findings 
in chronic nephritis, the uric acid tends to show an increase before 
there is any evidence of either urea or creatinine retention, but when 
it is demonstrated, it occurs in the order named. In general it may be 
said that such work has failed to furnish any evidence in favor of the 
view that eclampsia is in any way connected with the retention in the 
blood of the end- or by-products of metabolism. 

Furthermore, Plass has shown in this clinic that during the first 
few days following the subsidence of the eclamptic attack the non¬ 
protein constitutents of the whole blood or plasma rapidly increase in 
amount, and then promptly return to normal. While the explanation 
for this phenomenon is not clear, it has been suggested that preceding 
the attack those materials had been pathologically stored in the body 
tissues, whence they were abstracted during convalescence. Evidence in 
favor of such a supposition is afforded by the fact that the increases 
are most striking in patients with marked edema. That such changes 
are not due to an increased concentration of the blood is shown by the 
fact that determination of the total plasma protein indicates that in¬ 
creased hydremia or hydroplasmia immediately follows any procedure 
which leads to clinical improvement on the part of the patient. 

The blood sugar is usually normal, although as was first demonstrated 
by Ben thin, it may be somewhat increased during the convulsive period. 
There is no evidence of a carbohydrate insufficiency. The chlorides of 


ECLAMPSIA 


605 


the whole blood tend to be increased when the edema is considerable, 
which can probably be explained by the greater dilution of the blood 
in such cases. The carbon-dioxid combining power of the plasma is 
ordinarily diminished, thus indicating a considerable decrease in the 
bicarbonate content, although the readings obtained are usually not 
strikingly different from those obtained in normal pregnant women. It 
has been shown by Henderson and Morriss that in eclampsia the carbon- 
dioxid combining power of the corpuscles is increased; consequently, the 
values for whole blood may be normal, even though the ability of the 
plasma to hold carbon-dioxid is definitely reduced. During recovery the 
reserve alkali rapidly increases and frequently goes above normal at the 
end of a few days, only to drop abruptly to normal bounds. If the low 
bicarbonate content be regarded as an evidence of an acidosis, it is diffi¬ 
cult to reconcile it with the low ammonia coefficient of the urine, except 
upon the basis of a mild and fully compensated acidosis. 

The serum calcium is low during normal pregnancy probably as a 
result of the blood dilution, and no marked variations occur in eclampsia, 
except that in certain cases with pronounced edema, the values are some¬ 
what subnormal. In view of work now in progress upon the mineral 
constituents of the blood, it seems inadvisable to speculate concerning 
the significance of changes in any one element. Zangemeister has called 
attention to the fact that in many eclamptics there is an increased 
hydremia, and has used this observation as the basis for his attractive 
mechanical theory of the disease. The blood lipase is greatly increased 
(Whipple), whereas the catalase is within normal limits (Winternitz 
and Ainley). 

Pathology. —After Rayer and Lever had demonstrated the presence 
of albumin in the urine of women suffering from this disorder, it was 
generally believed that the fundamental pathological lesion in eclampsia 
was a nephritis, and for a long time the condition was considered to be 
identical with uremia. 

This view, however, was gradually abandoned when it was found 
that only a small proportion of the women suffering from chronic 
nephritis had eclampsia; and still further modifications became neces¬ 
sary after it had been shown that the urine does not necessarily contain 
albumin at the time of the eclamptic attack, Schroeder, Ingerslev, and 
Charpentier having collected respectively 62, 112, and 143 such cases 
from the literature. Its absence, however, does not necessarily disprove 
the renal origin of the disease, since Van de V elde has reported two 
instances of eclampsia in which the kidneys were markedly diseased, 
notwithstanding the fact that albumin was not demonstrable. 

For the most part, autopsy will reveal the presence of renal changes, 
which may be very marked in some and only slight in other cases. 1 he 
lesions are usually those of an acute nephritis with marked degeneration 
and necrosis of the epithelium of the convoluted tubules the so-called 
nephrosis of recent writers. Ordinarily, this is the only lesion, though 
occasionally the acute changes may be engrafted upon a chronic process. 
Prutz found that the kidneys were involved in all but 7 out. of 368 
autopsies collected from the literature, in which the description was 




606 


THE TOXEMIAS OF PREGNANCY 


sufficiently accurate to be of value. Acute or chronic nephritis was 
present in 46 and 11.6 per cent, of his cases respectively, while de¬ 
generative changes w'ere observed more frequently. His conclusions 
are stated as follows: “Notwithstanding the frequency of renal lesions, 

we are not justified in considering them as the anatomical substratum 
of eclampsia, for in many instances they are too insignificant; accord¬ 
ingly, it must remain a question whether they are not purely secondary 
in the greater proportion of the cases.” 

This view is also indorsed by Lubarsch, Schmorl, Bar and many 
other observers. Bouffe de Saint Blaise, moreover, states that the 
kidneys are often perfectly normal, and that lesions when present should 
be considered as secondary. On the other hand, Pels Leusden, Winckler, 
and Knapp observed pronounced renal changes in all of their cases, 
and were inclined to consider them as the characteristic lesion of the 
disease. Occasionally very extensive renal changes are observed, and 
Jardine and Kennedy, Rolleston, Schiippel and others have reported 
instances in which the entire cortex of the kidney had undergone com¬ 
plete and symmetrical necrosis. 

Consequently, the evidence at hand indicates that degenerative renal 
changes, while almost constantly present, are not, as a rule, sufficiently 
marked to justify one in considering them as the characteristic lesion of 
eclampsia, which must therefore be sought in some other organ. 

Halbertsma, in 1876, pointed out that the ureters were often en¬ 
larged and dilated, and was inclined to attribute the production of the 
disease to this condition. Prutz noted a similar finding 37 times in 
his analysis of 500 autopsies, and Lichtenstein in 15 out of 50 autopsies. 
As this incidence is scarcely greater than is noted in normal preg¬ 
nancy, it is evident that the abnormality cannot stand in an etiological 
relation to eclampsia. 

Although Jurgens and Klebs in 1886 had pointed out the existence of 
a hemorrhagic hepatitis in certain cases of eclampsia, it remained for 
Pilliet, in 1888, to direct our attention to characteristic hemorrhagic 
lesions in the eclamptic liver. His work was abundantly confirmed by 
Schmorl in 1893, who stated that he had found in every case lesions 
of the liver which he held to be more characteristic than those observed 
in the kidneys. These consist of irregularly shaped, reddish or whitish 
areas scattered through the entire organ and originating near the smaller 
portal vessels. Ordinarily they are readily seen with the naked eye, 
and on section give the liver a mottled appearance. Under the micro¬ 
scope they are recognized as areas of necrosis, involving the periphery 
of the individual lobules and the portal spaces, in which blood cells may 
or may not be present. Schmorl attributed their formation to de¬ 
generative changes following thrombotic processes in the smaller portal 
vessels, and considered that their presence justified the diagnosis of 
eclampsia without further knowledge of the history of the case (Fig. 
465). Flexner has shown that the earliest stages in the thrombotic 
process are due to the agglutination of red blood corpuscles. 

These findings were soon confirmed by all subsequent observers, and 
Schmorl, in 1902, observed them in 71 out 73 autopsies, while in the 


eclampsia 


607 


two negative cases there was a fresh thrombosis of the portal vein. I 
ha\e been able to demonstrate similar lesions in all the eclamptic livers 
which I have examined, and consider that they are absolutely character¬ 
istic , since, as far as we know at present, they do not occur in any other 
disease; and Opie, in his article upon zonal necroses of the liver, takes a 
similar view. Heinrichsdorlf reviewed the subject very thoroughly in 
1912, as did Goldzieher in 1919. While generally indorsing SchmorPs 

N. 



Fig. 465. —Eclamptic Liver. X 50. 

B. D., bile duct; C. V., central vein; N, periportal necroses. 


teaching, both of them hold that such lesions are not always present, 
but are pathognomonic when observed. 

Several observers have described the presence of hematomata of vary¬ 
ing size, just beneath the capsule of the liver, Prutz having recorded a 
fatal intraperitoneal hemorrhage from the rupture of such a structure. 

Varying statements have been made concerning the pathological find¬ 
ings in the brain—edema, hyperemia, anemia, thrombosis, and apoplexy 
being described as the main lesions. Prutz noted edema in 42 per cent., 
hyperemia in 35 per cent., and apoplexy in 13 per cent., while the brain 






608 


THE TOXEMIAS OF PREGNANCY 


was apparently normal in only 10 per cent, of his cases. Schmorl, 

58 out of 65 autopsies, in which the organ was examined, noted the 
presence of thrombi in the smaller cerebral vessels, and legal ded them 
as the cause of the small areas of necrosis which are so often observed. 

In most cases of eclampsia the heart is more or less involved, and 
was perfectly normal in only 8 out of 102 autopsies analyzed by Poliak. 
According to Schmorl, the changes usually consist in degenerative proc¬ 
esses in the myocardium, which are generally regarded as being due to 
eclampsia, though at times they may be attributed to the use of chloro¬ 
form in its treatment. 

Following Schmorl and Winckler, all investigators have demonstrated 
in the pulmonary capillaries the presence of giant cells, which they have 



Fig. 466. —Placental Giant Cell and Chorionic Villus in Blood Vessel of Tube 
Wall Some Distance from Placental Site. X 80. 


identified with the so-called giant cells of the placenta—namely, masses 
of syncytium. Schmorl formerly believed that their presence explained 
the origin of the thrombotic processes observed in various organs. But 
at present they are regarded as having no significance, as they can al¬ 
ways be found in pregnant women dead of other diseases. 

In patients who have died several days after the cessation of the con¬ 
vulsions, in addition to the lesions just described, bronchopneumonia or 
the various evidences of puerperal infection are frequently noted. 

It is apparent, therefore, that the main lesions in eclampsia are found 
in the liver, kidneys, heart, and brain; but in view of the marked dis¬ 
crepancy in the statements of the various authors concerning their rela¬ 
tive frequency and importance, it would seem, with the exception of the 
lesions in the liver, that the anatomical changes are not constant or 
characteristic. Accordingly, it must be assumed that the essential feature 
in the morbid process is the circulation of some as yet unknown “toxic” 











ECLAMPSIA 


609 


substance in the blood, which gives rise to lesions of varying intensity in 
the several organs. 

Etiology.—So many hypotheses have been advanced concerning the 
etiology of eclampsia that Zweifel has aptly designated it as “the disease 
I of theories.” Unfortunately, exact knowledge is still lacking. 

From the earliest periods it was considered as a disorder of the 
nervous system peculiar to pregnancy. This conception is no longer 

I entertained, though there is no doubt that the nervous system is in a 
condition of less stable equilibrium during pregnancy than at other 
times. This has been conclusively demonstrated by Blumreich and 
Zuntz, who showed that convulsions could be produced by the application 
to the cerebral cortex of far smaller quantities of powdered creatinin in 
pregnant than in non-pregnant animals. 

Following the discovery by Lever in 1843 that the urine of eclamptic 
patients contained albumin, the process was identified with Bright's 
disease, which had been described a few years previously. From then 
onward, but more particularly after 1880, the etiology of eclampsia 
has been industriously studied, and every important contribution to 
! medical thought has been applied to its solution. Up to the present, 
however, none of the explanations advanced has stood the test of criticism, 
and we are still ignorant of its actual cause. Nevertheless, this great 
expenditure of effort has not been wasted, since it has led to the elimina¬ 
tion of many theories, and has thus prepared the way for the eventual 
discovery of the ultimate cause of the disease. 

In order for any theory to be regarded as acceptable, it must explain 
satisfactorily certain pathological and clinical facts, of which the follow¬ 
ing may be mentioned: A. The genesis of the characteristic hepatic 
lesions. B. The predisposing influence of primiparity, multiple preg¬ 
nancy and hydramnios. C. That the disease is more common in north¬ 
ern countries than in the tropics. D. That its incidence increases as 
pregnancy approaches term. E. That marked edema is usually a favor¬ 
able sign, while its absence adds to the gravity of the prognosis. F. 
That true eclampsia rarely occurs, whereas chronic nephritis gives 
rise to increasingly serious trouble in each succeeding pregnancy. G. 
That intrauterine death of the fcetus is usually followed by improvement, 
and H. That a milk diet, which is high in protein and mineral con¬ 
stituents, is as efficacious as one low in protein and free of salt. 

Some idea of the scope of the researches may be gained by consider¬ 
ing the following twelve headings: 

I. Uremia. 

II. Bacterial origin. 

III. Auto-intoxication. 

IV. Biological reactions. 

V. Entrance of foetal elements into the maternal circulation. 

VI. Action of foetal metabolic products. 

VII. Action of decomposition products of the placenta. 

VIII. Alterations of maternal metabolism. 

IX. Endocrine disturbances. 









CIO 


THE TOXEMIAS OF PREGNANCY 


X. Mammary toxemia. 

XI. Effect of dietary alterations. 

XII. Physicochemical changes. 

I. Uremia.— It has already been mentioned that following the ap¬ 
pearance of Lever's article, eclampsia was identified with uremia, and 
that view was slowly abandoned only after it had been demonstrated that 
the lesions of eclampsia and of chronic nephritis had little in common. 
Consequently, it is now generally recognized that the two processes are 
quite distinct, but at the same time it must be remembered that clinical 
differentiation is sometimes difficult, and occasionally impossible. 

II. Bacterial Origin.— Delore and Rodet of Lyons, in 1884, sug¬ 
gested bacterial invasion as a possible etiological factor, but adduced no 
evidence in support of such a view. The first investigations were made by 
Doleis in 1885, and following him many observers reported that they had 
cultivated various bacteria from the urine, blood, and tissues of eclamptic 
women, but their findings were so contradictory as to be of little value. 
On the other hand, all later investigators working with modern technical 
methods have obtained negative results, so that it is generally agreed 
that eclampsia is not of bacterial origin. Stroganoff in 1923 suggested 
that the possibility of infectious origin should be constantly borne in 
mind, as it would best account for certain of the clinical peculiarities 
of the disease. As his statement is not based upon experimental work, 
it is scarcely entitled to consideration. 

According to Talbot and LaVake, the existence of focal infections 
in the tonsils, teeth and other organs, plays an important part in the 
production of the disease, and Bugbee holds that infections of the urinary 
tract do likewise. While many eclamptic women doubtless harbor such 
foci of infection, no satisfactory evidence has been adduced to indicate 
that they play any essential part in its etiology. 

III. Auto-intoxication.— The work of Bouchard upon auto-intoxi¬ 
cation, led Riviere to put forward the theory that eclampsia was an auto¬ 
intoxication resulting from the heaping up of some substance in the 
system during pregnancy, holding that its presence was indicated by an 
increase in the toxicity of the blood serum and by a decrease in that of 
the urine. This conception was placed upon an apparently secure foun¬ 
dation by the work of Chamberlent, Tarnier and their students, who 
showed that the urine of women suffering from eclampsia, or just about 
to be attacked by it, when injected into the circulation of animals was 
less toxic than normal urine, while the toxicity of the blood serum was 
definitely increased. They concluded, therefore that some poisonous sub¬ 
stance, which should have been excreted by the kidneys, was accumulat¬ 
ing in the blood serum, thereby giving rise to the hepatic and renal 
lesions, which still further accentuated the condition. 

The earlier work along these lines was in great part confirmatory, 
but as it was gradually learned how complicated are the conditions at¬ 
tending such experiments, more and more doubt was cast upon such 
conclusions; so that it is now generally admitted that satisfactory evi¬ 
dence has not been adduced in support of the view that a “toxin” 


ECLAMPSIA 


611 


in the blood serum is the cause of the disease, more particularly as 
Obata in 1919 was unable to detect any increased toxicity in his animal 
experiments. 

I\. Biological Reactions.— Following SchmorPs suggestion that 
the characteristic hepatic lesions were possibly due to the entrance of 
placental cells into the maternal circulation, the problem was approached 
from the biological side, and the phenomena of agglutination and 
hemolysis, and later those of anaphylaxis, were studied in the hope that 
they might throw light upon the subject, 

(a) Agglutination and Hemolysis .—After Flexner had shown that 
the agglutination of red blood corpuscles was the immediate cause of 
the thrombosis which initiates the characteristic peri-portal necroses, and 
‘ Pearce had demonstrated that similar thrombi could be produced ex¬ 
perimentally by the injection of hemagglutinative sera, numerous at¬ 
tempts were made to associate such phenomena with the etiology of 
eclampsia. Leith Murray believed that, while agglutination leads to 
necrosis, hemolysis merely results in degenerative changes, and that the 
existence of a special endothelial toxin—hemorrhagin—mut be invoked 
in order to explain the production of hemorrhagic lesions. Accordingly, 
he considered that the toxemias of pregnancy are attributable to the 
action of a triple toxin, and that the lesions and symptoms will vary 
according to which one of the three factors predominate. While in¬ 
genious and interesting, this theory has not been substantiated. 

Dienst in 1905 attempted to demonstrate that the agglutinative 
changes occurring in eclampsia were the result of the invasion of the 
maternal organism by foetal cells, having previously shown that the 
maternal serum would agglutinate the blood cells of the foetus. He at 
once realized that such a theory could not be maintained unless it were 
shown that foetal blood could gain access to the maternal circulation, 
and he thought that this could be demonstrated in eclamptic women. 
Notwithstanding his advocacjq Dienst soon abandoned this view in 
favor of his original one that the prime factor consists in an excess of 
fibrin ferment in the maternal blood. 

In 1922, McQuarrie studied the question of isoagglutination in 180 
mothers and their newly born babies in our service. He found that 
at the time of birth the blood grouping was already established in a 
surprisingly large number of infants, and that the maternal serum 
agglutinated the red cells of the latter in 23 per cent, of his cases, 
whereas, the reverse reaction was demonstrable in less than 3 per cent. 
Moreover, he found that mild or severe toxemic symptoms occurred 16.5 
times more frequently when the maternal and foetal bloods were in¬ 
compatible than when they belonged in the same isoagglutination groups. 
At the same time, he cautiously stated that the number of cases was too 
small to justify binding conclusions, and that the ultimate fate of his 
theory must be dependent upon the demonstration that foetal blood 
cells can gain access to the maternal circulation, which is still lacking. 

W. M. Allen continued similar observations in our service during 
1923. His, as yet unpublished, work was based upon the study of 400 
additional women and their children—of whom 350 were normal, 22 



612 


THE TOXEMIAS OF PREGNANCY 


were suffering from pre-eclamptic toxemia, while 28 had actual eclampsia. 
Contrary to McQuarrie, he found that the percentage of cases in which 
the maternal and foetal blood was incompatible was practically identical 
in each group—namely 20.8, 22.7, and 25 per cent, respectively. In 
other words, his investigations afford no basis for the belief that agglu¬ 
tinative reactions play any part in the production of eclampsia, and 
thus effectively dispose of a theory which was attractive from many 
points of view. Furthermore, the outcome of his study emphasizes 
once more the well-known danger of drawing conclusions from insuffi¬ 
cient data; as at first his findings apparently gave promise of confirm¬ 
ing McQuarrie’s conclusions, whereas, when the larger series was com¬ 
pleted, they conclusively disproved them. 

(b) Anaphylaxis .—Rosenau and Anderson in 1908 suggested that 
eclampsia might represent an anaphylactic reaction. This idea was still 
further elaborated by Thies and Lockeman, and by Grafenburg, who, 
after an extensive series of experiments, held that the mother was 
sensitized during pregnancy by small quantities of foetal protein, and 
would go into anaphylactic shock if a quantity of foetal blood were 
suddenly introduced into her circulation. They identified the con¬ 
dition with eclampsia, and claimed that the liver and kidneys presented 
characteristic lesions. On the other hand, the researches of Johnstone, 
Murray, E. Zweifel and others have led to negative results, so that it is 
probable that Rosenau’s findings must be attributed to the introduction 
of the products of placental autolysis. 

A somewhat similar theory has been advanced by Mayer, who at¬ 
tempts to ascribe the striking reduction in the incidence of eclampsia, 
which occurred in Central Europe during the war, to relative sexual 
abstinence. He assumes that following coitus certain elements of the 
sperm are normally absorbed through the vaginal or uterine mucosa and 
thus sensitize the woman. Consequently, he holds that the frequent 
repetition of coitus might lead to a pseudo-anaphylactic reaction, namely 
pre-eclamptic toxemia or eclampsia. As such opportunities were greatly 
diminished during the war, he suggests that the lower incidence of 
eclampsia might be attributed to it. Such an hypothesis seems fanciful, 
more particularly since the facts can be explained more rationally upon 
the basis of the dietary changes incident to the food blockade, as well 
as by the observation that women who have become pregnant after a 
single coitus are not immune to the eclampsia. 

Y. The Entrance of Fcetal Elements into the Maternal 
Blood. —Veit, in 1902, promulgated an hypothesis along the lines of 
Ehrlich’s side chain theory, which for a time bid fair to solve the prob¬ 
lem. Notwithstanding its failure to do so, his work has served to direct 
attention to the “biological” aspects of the problem and has been the in¬ 
centive for a large amount of investigation. This theory was based upon 
the fact that at all periods of pregnancy varying amounts of foetal ecto¬ 
derm, and even fragments of chorionic villi, are constantly gaining access 
to the maternal circulation—the process being designated as “deporta¬ 
tion.” Veit contended that such elements acted as a poison—svncvtio- 
toxin, which is normally rendered innocuous by a supposititious antibody 







ECLAMPSIA 


613 


■—syttcytiolysin, which develops in the maternal serum. If, however, for 
any reason, the former is present in quantities too great to be neutralized, 
or if the elaboration of the latter is interfered with, symptoms of poison¬ 
ing result and eclampsia eventually follows. 

He considered that the correctness of the theory was established when 
he found that the injection of an emulsion of human placenta into the 
peritoneal cavity of rabbits was followed by albuminuria and sometimes 
by death. In drawing his conclusions, however, he overlooked the fact 
that similar results would follow the introduction of any heterogeneous 
animal tissue, and also that nature performs a much more ideal experi¬ 
ment whenever the rupture of a tubal pregnancy leads to the extrusion 
of the ovum into the peritoneal cavity. The fact that eclampsia does 
not supervene under such conditions speaks strongly against the correct¬ 
ness of this view. Ascoli, on the other hand, held that the disease was 
due to an excessive production of syncytiolysin. 

VI. Foetal Metabolic Products.— Fehling in 1899 and Dienst in 
1902 advanced the theory that eclampsia is due to intoxication by prod¬ 
ucts of the foetal metabolism. The advocates of this view lay great stress 
upon the fact that death of the foetus in utero is in many cases promptly 
followed by cessation of the convulsions and the recovery of the patient, 
but particularly upon the fact that the children of eclamptic mothers 
occasionally develop convulsions shortly after birth and present char¬ 
acteristic hepatic lesions at autopsy. Cases of this latter type were 
collected and critically considered in DiensFs monograph. 

Observations of neither type, however, can be relied upon to sup¬ 
port the contention that eclampsia is foetal in origin, except in so far 
as it must be conceded that the development of the foetus is the essential 
function of pregnancy, and that its death must lead to radical changes 
in the entire process. On the other hand, the presence of lesions in the 
foetus is noted so rarely, that it would seem more rational to attribute 
them to the action of substances derived from the mother, which had 
passed through the placental filter, than to regard them as a manifes¬ 
tation of a primary foetal disturbance. Furthermore, the occurrence 
of so-called intercurrent eclampsia, in which the patient recovers from 
the convulsive seizure and later gives birth to a normal living child, 
speaks against such a view. 

The argument that the foetal origin of the disease is disproved by 
the occasional association of eclampsia with hvdatidiform mole does 
not appear convincing, as it is conceivable that the metabolic processes 
incident to the continued growth of the chorionic villi may not differ 
materially from those of the normal foetus. However this may be, 
little is said at present concerning the total origin of eclampsia, except 
by the exponents of the agglutination theory, and it has been intimated 
above that it need not be considered seriously. 

VII. Placental Decomposition Products. — ( a) Placental Endo¬ 
toxins.— Following Veit’s theory numerous investigators, including Liep- 
mann, Freund, and Guggisberg, have attempted to prove that eclampsia 
is due to endotoxins produced by the normally situated syncytial cells. 
They found that the injection into experimental animals of emulsions 




614 


THE TOXEMIAS OF PREGNANCY 


or extracts of placental tissue were usually followed by rapid death and 
sometimes by convulsions, but at autopsy the lesions were not character¬ 
istic. Furthermore, Lichtenstein demonstrated that the results were in 
great part mechanical, and that large quantities of such preparations 
could be injected with impunity provided all suspended particles had 
been previously removed by filtration. As subsequent writers have con¬ 
firmed his observations, it may be stated that there is no evidence to 
indicate that eclampsia can be produced by normal placental tissue, 
provided suitable precautions have been taken in the preparation of the 
material used for experimentation. 

(b) Autolysis .—Upon repeating Rosenau's work, Leith Murray, and 
Johnstone proved that his results were dependent upon the fact that 
he had autolyzed the placentae for several hours before utilizing them 
for injection into animals. Not only did they demonstrate that un- 
autolyzed placental tissue failed to give any reaction, but they were 
able to reproduce the toxic symptoms, which he described by the use 
of extracts prepared from autolyzed liver. How difficult it is to elimi¬ 
nate from experimental work the effects of autolysis is evident from the 
contention of Dryfuss that it may occur even while the placenta is still 
functioning in situ. 

The toxicity of the autolytic products of the placenta was utilized 
by Y'oung as the basis of his theory concerning the origin of eclampsia. 
He emphasizes the association of toxemia with infarct formation, and 
holds that the clinical symptoms are due to autolytic products, which 
have originated intra vitam. In a communication prepared in collabora¬ 
tion with D. A. Miller in 1921, he states that the failure to detect 
placental infarction in many cases of fulminating eclampsia is due to the 
fact that the changes are ultramicroscopic, but yet are sufficient to flood 
the patient with toxic autolytic products. 

The association of red infarct formation with severe nephritic 
toxemia has long been known, but most observers have not described 
them in connection with eclampsia, although they are sometimes present 
in the placentae of apparently normal pregnant women. Furthermore, 
McNalley and Dieckmann, as well as Haffner, have studied large series 
of placentae and have failed to detect any relationship between infarct 
formation and toxemia. When the placentae were carefully examined in 
slabs of about one centimeter in thickness, they found smaller or large 
red infarcts in about one-third of all specimens, while toxemic symptoms 
were present in less than one-tenth of the patients, and even in these 
infarcts were not always noted. In general, I think it safe to say that 
infarcts, when present, should be regarded as secondary to the toxemic 
process, and not as its cause, as Young believes. 

(c) Lipoids .—The placenta has been analyzed by various investi¬ 
gators in the attempt to discover some substance which might produce 
toxic symptoms, but in general the results have not been encouraging. 
Considerable attention has been paid to its lipoid constituents, and 
various fatty substances have been isolated. For example, Freund and 
Mohr considered that they had solved the problem of hemolysis when 
they isolated oleic acid or sodium oleate, but it is now generally believed 


ECLAMPSIA 


615 


that these substances are merely derived from the fat normally present 
tn the placenta. 

Leith Murray showed that eclamptic placentae contained larger 
amounts of soluble lipoids than normal organs, and held that such sub¬ 
stances possessed marked hemolytic properties. He failed, however, in 
isolating a specific compound. Furthermore, Schonfeld in 1921, claims 
to have isolated a strong convulsant poison from the alcohol-acetone- 
glycerine extract of normal placentae. He considers that it produces 
lesions similar to those occurring in eclampsia, but, from his description, 
this seems doubtful. Moreover, it is difficult to believe that any such 
substance is of etiological significance, since ordinary placental extracts 
do not produce either symptoms or lesions when injected into animals 
under suitable precautions. 

VIII. Alterations in Maternal Metabolism.— The first meta¬ 
bolic hypothesis was advanced by Spiegelberg, who in 1870 suggested that 
the circulation of ammonium carbonate in the blood was responsible for 
the seizures. Chemical examination having failed to substantiate the 
statement, it was soon abandoned. It is, however, of historical interest, 
as it represents the first of a long series of attempts to correlate the 
manifestations of the disease with disturbed metabolism. Some years 
later, Ludwig and Savor considered the offending product to be carbamic 
acid, which they held was formed because of the inability of the liver to 
complete the synthesis of urea. 

(a) General Metabolism .—Satisfactory metabolic studies have not 
as yet been made on account of the great difficulty in making total col¬ 
lections in eclamptic patients, but from numerous investigations it is 
evident that the nitrogenous metabolism is seriously disturbed. The 
earlier workers, who dealt entirely with the percentage composition of 
the urine, demonstrated that the urea accounted for an unusually small 
proportion of the total nitrogen—the so-called rapport azoturique, while 
the percentages for amino-acids, creatinine, uric acid, ammonia, and 
rest nitrogen were increased. As a result, the theories of suboxidation 
and imperfect desamidization were expounded and for a time were gen¬ 
erally accepted, but with increasing biochemical knowledge they have in 
great part yielded to other ideas. 

Zweifel attempted to find some imperfectly oxidized body in the 
urine, and succeeded in isolating considerable quantities of saicolactic 
acid, which was also found in the cerebrospinal fluid by Fiith and 
Lockemann. It is now generally agreed that its presence must be re¬ 
garded as the result rather than the cause of eclampsia. The idea of 
the existence of an acidosis has become quite firmly fixed, and while 
the hydrogen-ion concentration of the blood may be somewhat increased, 
it scarcely exceeds' that occurring in normal pregnancy, and is clearly 
not an index of the severity of the attack. 

The lowered urea output w-as regarded as an indication that the 
liver was not properly fulfilling its function as the chief urea-forming 
organ of the body, and consequently it was assumed that poisonous in¬ 
completely oxidized substances must be circulating in the blood. In 
addition, it was believed that the liver was incapable of fulfilling its 










G16 


THE TOXEMIAS OF PREGNANCY 


detoxifying function. All of these assumptions are probably incorrect, 
as animal experimentation lias shown that much more extensive de¬ 
struction of liver tissue than is noted in eclampsia must occur before 
these functions become seriously impaired. Furthermore, Folin has 
demonstrated that the tissues in general are able to produce urea, and 
has emphasized the relationship between the total nitrogen of the food 
and the percentage composition of the urine, so that it is likely that 
the lowered urea output can be explained by the decrease in the total 
nitrogen excretion. 

The increased percentage output of the amino-acids has been utilized 
to support the theory that the liver is functioning imperfectly. Van 
Slyke and Losee, however, have demonstrated that the excretion of these 
substances is within normal limits, and they were also unable to detect 
any increase in their amount in the blood, although such increases occur 
in acute hepatic degeneration, as represented by acute yellow atrophy 
of the liver and chloroform poisoning. On the other hand, the 
increased percentage of undetermined, or rest, nitrogen has remained 
unexplained, notwithstanding repeated efforts to discover the presence 
of some unusual nitrogen-containing body. Pearce and Jackson have 
shown that in animals focal and diffuse necroses of the liver are asso¬ 
ciated with the presence of a high undetermined nitrogen fraction in the 
urine, and numerous observations indicate that a similar condition ob¬ 
tains in the blood of eclamptic patients, but, in view of the negative 
results following experimental injections, it seems unlikely that such 
substances possess a special toxic action. 

As has been indicated, the urea output, which is greatly diminished 
during the acute stages of the disease, increases rapidly after delivery 
and is excreted in several times the normal amount. Sikes attributed 
this to an accumulation of precursors of urea in the system, while 
Slemons insists that it is due to involution of the uterus. Plass rightly 
holds that the excess, over the normal puerperal output, must be re¬ 
garded as proof that an actual retention had taken place in the tissues. 

According to Wells, changes in the sulphur metabolism also indicate 
that the body oxidations are not proceeding at the normal rate. This 
is evidenced by the fact that a greater amount than usual of sulphur 
is eliminated in unoxidized form, as compared with sulphur dioxid. 

Chloride retention has been emphasized by Zinsser, and Biittner, 
who have shown that the elimination of chlorides is decreased during 
the eclamptic attack, and suddenly increases as improvement occurs. 
According to Zangemeister, this is associated with an increased per¬ 
centage of plasma chlorides and with a liydroplasmia, which he regards 
as the essential change. 

(b) Blood Changes .—Chemical analysis indicates that the blood of 
eclamptic women differs somewhat from that of normal pregnancy. 
Ordinarily the alterations are quantitative rather than qualitative in 
character, which apparently indicates that they are of secondary impor¬ 
tance. As was indicated in the section upon pre-eclamptic toxemia, 
there is little or no retention of the non-protein nitrogenous constituents, 
as occurs so frequently in nephritic conditions. 







ECLAMPSIA 


617 


In view of the fact that a low blood calcium content is recognized 
as an important factor in bringing about increased nervous irritability 
—such as tetany, its behavior in normal pregnancy, and especially in 
eclampsia, has been studied. Ivehrer and others have found that it 
falls below the usual limits in normal pregnancy, and is still further 
decreased in eclampsia. Plass in our service was able to confirm the 
first observation, but not the second, and considers the former a result 
of the hydroplasmia which characterizes normal pregnancy and some¬ 
times becomes exaggerated in toxemic patients presenting marked edema. 

Extensive investigations along these lines are now in progress in 
our laboratory, but are not yet ripe for discussion. It may be said 
that they indicate considerable perversion of the entire inorganic met¬ 
abolism, but the changes are probably secondary in character, and thus 
can scarcely be reckoned with as primary factors In the causation of 
eclampsia. 

(c) Ferments .—Schmorl originally suggested that the extensive 
thrombosis accompanying the disease might be due to the action of 
fibrin ferment (thrombin). This view has been especially advocated 
by Dienst, who holds that an increase in fibrin ferment, together with 
a higher fibrinogen and an abnormally low antithrombin content of the 
plasma, can account for all the observed phenomena. He believes that 
unusually large amounts of thrombin are produced in the placenta from 
leukocytes, and, as the diseased liver can no longer produce the neces¬ 
sary antithrombin, intravascular coagulation results. In 1920 he at¬ 
tempted to align his theory with the newer work of Zangemeister and 
others on the changes in the capillaries, and has adduced evidence in 
support of his view. The increase in the amount of fibrin ferment is 
apparently capable of proof, but it is generally believed that it is not 
the primary cause of eclampsia. 

It has been suggested that steapsin or lipase may have some etio¬ 
logical significance, but the evidence at present available indicates that 
their increase is secondary to the liver necrosis. Whipple has definitely 
shown that the latter is definitely increased in experimentally produced 
liver necrosis, and that in eclampsia the degree of liver injury, as de¬ 
termined at autopsy, is closely paralleled by the increase in the blood 
lipase. 

( d) Physical Changes in the Blood .—Filth and Kronig and other 
observers have directed attention to an increase in the viscosity of the 
blood of pregnant women, which becomes accentuated in eclampsia; 
while Abderhalden, Fahraens and others have shown that in freshly 
drawn eclamptic blood the red cells sediment more rapidly than usual. 
These phenomena have been variously interpreted, and it has been as¬ 
sumed that they may be concerned in the production of the initial throm¬ 
bosis in the parenchymatous organs. However this may be, it seems 
safe to regard such changes as secondary to some more fundamental 
alteration. 

IX. Endocrine Disturbances. —As soon as the importance of the 
glands of internal secretion was appreciated, it became evident that their 
functions are so altered during pregnancy that a new endocrine balance 






618 


THE TOXEMIAS OF PREGNANCY 


is probably established, and many attempts have been made to connect 
them with the various types of toxemia, but thus far nothing definite has 
been elicited. 

After it had been established that the thyroid gland undergoes physio¬ 
logical hypertrophy during pregnancy, Lange and others suggested that 
its absence might predispose to toxemia. Nicholson, Ward and others 
soon put the suggestion into practice and recommended the administra¬ 
tion of thyroid extract in the treatment of pre-eclamptic toxemia and 
eclampsia. Notwithstanding a considerable amount of work along such 
lines, the consensus of opinion is that abnormalities in the thyroid 
secretion play no part in the causation of eclampsia, and that its treat¬ 
ment by thyroid extract is useless. 

Yassale and Zangfrongini ascribed a similar function to the para¬ 
thyroid glands. It is now generally recognized that insufficient secretion 
on their part leads to the production of tetany, but not to eclampsia. 
Furthermore, at autopsy upon patients dying from the latter disease, 
no lesions can be discovered in the parathyroids. Consequently, Seitz 
must be correct in holding that they are in no way concerned in its 
production, and that treatment by means of parathyroid extract is irra¬ 
tional. 

Hofbauer, on the other hand, believes that the cause of eclampsia 
is associated with hyperfunction of the hypophysis and adrenals result¬ 
ing from deficient secretion on the part of the ovaries. He, consequently, 
recommends ovarian therapy with the idea that it may restore the normal 
endocrine balance, but careful perusal of his article leaves one skeptical 
as to its merits. 

X. Mammary Toxemia.— Sellheim in 1910 suggested the possibility 
that eclampsia might be due to toxins elaborated in the mammary glands, 
basing the suggestion upon the supposed similarity between the partu¬ 
rient paresis of cattle and human eclampsia, and he even amputated 
the breasts from a patient in whom eclampsia had proved refractory 
to other treatment. 

Two years later Healy and Ivastle stated that the two diseases were 
identical, and that they could produce eclampsia experimentally by in¬ 
jecting into the peritoneal cavity of guinea pigs small quantities of 
colostrum obtained from cows suffering from parturient paresis. At 
autopsy they found renal and hepatic lesions, which they considered 
suggestive of those observed in eclampsia. I am not prepared to accept 
this belief, for the reason that examination of tissues, which these 
investigators kindly sent me, showed that the liver lesions were more 
closely allied to those occurring in acute yellow atrophy of the liver than 
to the periportal necroses which characterize eclampsia. 

In any event parturient paresis is an interesting disease, which de¬ 
serves more extended study. As is well known, it occurs in well-nourished 
cows shortly after labor, and formerly almost always ended in death; 
while now recovery almost universally follows the injection of air into 
the udders. It is characterized by paralysis, coma, convulsions, albu¬ 
minuria, the presence of casts, and by a pronounced change in the 
nitrogenous partition. Owing to the fact that it is now rarely followed 


ECLAMPSIA 


619 


by death, little is known concerning its pathology, with the exception 
oi the statement of Delmer that it is associated with lesions of the 
liver and kidneys. 

XI. Dietary Alterations.— The startling reduction in the inci¬ 
dence of eclampsia in Central Europe during the World War, with return 
to the prewar frequency after its conclusion, has led to some interesting 
speculation concerning the origin of the disease. The articles of Buge, 
Warnekros, Gessner, Yaro, Buiz and others show that the reduction 
was most pronounced in the cities, and was minimal, or lacking, in the 
open country. They explained the difference by assuming that the 
effects of the food blockade were felt most in the cities, but were scarcely 
noticed in the country, where the farmers took care that the needs of 
their families were supplied before disposing of their surplus stock. 
As the lack was greatest in meats and fats, the diet was restricted so 
far as possible to food of vegetable origin; consequently, the relative 
disappearance of eclampsia was generally attributed to restriction in 
the use of the former, and various attempts were made to explain the 
results, and attention was directed to the conditions prevailing in tropical 
countries in which eclampsia occurs but rarely. Gessner, on the other 
hand, was inclined to discount the effect of the change in diet, and to 
attribute the change to increased physical labor and to the loss of body 
fat. In support of his contention, he pointed out that, while the food 
control was rigidly enforced during the year 1919, the incidence of 
eclampsia, nevertheless, returned to the prewar figure, and, as the only 
important change in conditions was the cessation of war work, he believed 
that the latter was implicated. 

Whatever the true explanation may be, this experience seems to 
indicate that hard physical labor and an approach to a vegetable diet 
can play a definite part in the prophylaxis of eclampsia, and raises the 
question as to why milk, the other great prophylactic, should have a 
similar effect. At first glance, this appears improbable, as the latter 
contains large amounts of animal protein and fat, so that the only 
point in common between a milk diet and the German war diet is the 
presence of a high inorganic salt content. 

Whether an abundant supply of inorganic material has any prophy¬ 
lactic effect, or whether an actual or relative mineral deficiency is associ¬ 
ated with the causation of eclampsia can only be decided in the future, 
but it is interesting to consider that one of the by-effects of the war 
has been to direct our attention to the mineral metabolism. 

XII. Physicochemical Changes.— For some time Zangemeister has 
believed that edema of the brain is the essential cause of eclampsia, and 
has thus resuscitated the Traube-Bosenstein theory which was so popular 
sixty years ago. In 1919 he advanced his hydrops gravidarum theory, 
according to which, under the influence of some substance connected 
with the pregnancy, the permeability of the capillary walls becomes 
increased, with the result that fluid escapes into the tissues, giving rise 
to edema and anasarca. To overcome the increased peripheral resistance 
the blood pressure is raised, albuminuria results from the edema of the 
secreting renal cells, and the headache and eye signs from swelling of 








620 


THE TOXEMIAS OF PREGNANCY 


cl 

‘I 


the brain and retina—or as he tersely expressed it in 1921—“the long 
sought for cause is indirectly water." In view of Plass’ results indi¬ 
cating a tissue retention of various crystalloid metabolic products, it 
seems probable that the water which escapes into the tissues must carry 
with it certain other constituents of the plasma. 

These are, however, two serious objections to Zangemeister’s theory: 
first, that it does not explain the production of the characteristic hepatic 
lesions, and second, that it takes no account of the cases of eclampsia 
without edema, which in my experience offer the most serious prognosis. 

Zangemeister’s theory is supported to some extent by the observa¬ 
tions made by means of the capillary microscope, whose clinical use 
was introduced by Weiss in 1916, and extended into obstetrics particu¬ 
larly by Hinselmann. In this way it is possible to observe the circulation 
through the capillaries at the base of the finger nails, and to note 
peculiarities in its behavior. Hinselmann in various articles has pointed 
out that in toxemia and eclampsia spasmodic contractions of the capil¬ 
laries are constantly recurring, which result in periods of complete 
cessation of the current and occasionally in actual reversal of direction. 
While such changes are probably secondary in character they are very 
suggestive, and Hussy has demonstrated in the eclamptic blood a vaso¬ 
constrictor substance, which he believes is responsible for such changes. 

In summing up the subject, it is apparent that the cause of eclampsia 
has not yet been discovered, but at the same time we have learned tha 
many factors, which were formerly considered as satisfactorily explaining 
its production, need to be considered no longer. Furthermore, it must 
be admitted that the treatment of the disease must remain empirical 
and unscientific so long as we are ignorant of its primary cause. 

Diagnosis.—Except for the possibility of confusion with purely 
uremic conditions, the recognition of eclampsia usually offers no diffi 
culty. It might be confounded with acute poisoning from strychnin, 
phosphorus, or nitrobenzol, as in a case reported by Schild. However, 
such instances are extremely rare, and careful inquiry into the history of 
the patient should prevent error. Generally speaking, one is much 
more likely to make the diagnosis of eclampsia too frequently than to 
overlook the disease, as epilepsy, acute yellow atrophy of the liver, and 
even hysteria may simulate it. Consequently they should be borne in 
mind whenever convulsions or coma appear during pregnancy, labor, or 
the puerperium, and must be excluded before a positive diagnosis is 
made. Occasionally it is impossible to make an accurate clinical diag¬ 
nosis, and in such cases only the finding of characteristic lesions at 
autopsy will enable one to be positive as to the nature of the affection. 

Prognosis.—The prognosis is always serious, eclampsia being one of 
the most dangerous conditions with which the obstetrician has to deal. 
Dublin, in 1918, having pointed out that it, with the other toxemias of 
pregnancy, was responsible for 26.4 per cent, of the total mortality from 
childbirth. The average mortality varies from 20 to 25 per cent., while 
that of the child approaches 50 per cent. In 2,005 cases of eclampsia 
occurring in Great Britain and analyzed by Eden, the mortality was 22.5 
per cent., ranging from 10.3 per cent, in Dublin to 25.1 per cent, in the 














ECLAMPSIA 


621 


North of England. As will be stated below the adoption of more con¬ 
servative methods of treatment has led to a considerable improvement 
in prognosis, and Stroganoff in 1923 reported a mortality of only 1.7 per 
cent, in 230 personal cases, which, I fear will be approximated by few. 

The prognosis was formerly thought to be more gloomy when the 
seizures come on before or during parturition than after delivery, but 
with the adoption of more conservative methods of treatment the death 
rate in the former has become materially diminished, while in the 
latter it has remained stationarv. Thus, in 115 cases occurring in our 
service during the ten years ending in 1922, the gross mortality was 
14.7 per cent.—with percentages of 13 and 21.7 in the two groups, 
respectively. 

There is considerable discrepancy of opinion concerning the relative 
prognosis in primiparous and multiparous women. Thus, Goldberg and 
Lichtenstein state that the disorder is twice as dangerous in multiparae. 
Olshausen, on the other hand, believes that there is no difference in the 
two groups, and his contention is borne out by Eden’s figures, which 
show a mortality of 22.9 and 27.4 per cent., respectively. In all proba¬ 
bility the prognosis really depends much more upon the severity of the 
attack than upon the number of children that the woman has borne. 

In individual cases it is often difficult to predict the course of the 
disease, some patients dying in the first seizure, while others recover 
after more than 30, Jardine reporting a recovery after 200 convulsions. 
Seitz states that the prognosis becomes worse with each convulsion up to 
20 or 30, but that a greater number does not necessarily add to the 
gravity of the case, the prognosis depending upon the rapidity with 
which they follow one another and the duration of the coma after each 
attack. 

Valuable prognostic data ave also afforded by the condition of the 
pulse and temperature. When the former is of fair quality between 
the attacks the outlook is usually good; whereas a weak, rapid, and 
thready pulse usually indicates a fatal issue, particularly if the tempera¬ 
ture is high. The persistence of a high arterial pressure is always of bad 
prognostic significance, even when the other symptoms seem to improve. 
Complete anuria and the inability to sweat in a hot pack are ominous 
symptoms. Apoplexy, paralysis, and edema of the lungs are serious 
complications and usually end in death. 

Eden distinguishes between mild and severe cases, and believes that 
he has to deal with the latter whenever any two of the following seven 
symptoms are present: 1, coma; 2, pulse rate above 120; 3, temperature 
103 or higher; 4, blood pressure above 200; 5, more than ten fits; 6, 
sufficient albumin to become solid on boiling; and 7, and least important, 
the extent of edema. Of 706 cases, in which the data were sufficiently 
comprehensive to permit such differentiation, 56 per cent, were mild and 
44 per cent, severe, with mortalities of 6.6 and 37.2 per cent., respec¬ 
tively. 

If the eclampsia comes on during pregnancy the prognosis is very 
favorably affected by the death of the foetus, the convulsions usually 
ceasing soon afterward. The presence of marked edema in general jus- 








622 


THE TOXEMIAS OF PREGNANCY 


tifies a more favorable prognosis than when there is no demonstrable 
swelling, which suggests that the retention of fluid in the tissues should 
be regarded as a protective mechanism, and possibly serves to withdraw 
temporarily from the circulating blood certain substances which may 
do harm. 

If the patient recovers, it is unusual for eclampsia to occur in subse¬ 
quent pregnancies. The observations of Slemons, and Lepage clearly 
show that one attack confers a relative immunity for the future. In 
my experience, a woman who has had eclampsia is less disposed to the 
disease in future pregnancies, than one who has never had it. On the 
other hand, in patients suffering from chronic nephritis the recurrence 
of uremic convulsions is not uncommon. 

The foetal mortality must always be high since the disease frequently 
appears while the child is still premature, when its chances of living 
would be only moderate even were the mother not suffering from a 
serious disease. Moreover, except in the postpartum variety, the thera¬ 
peutic measures adopted in the interests of the mother still further 
prejudice its chances. For these reasons, a foetal death rate of approxi¬ 
mately 50 per cent, is not surprising, and in our hands but little more 
than one-third of the children left the hospital with their mothers. 

Treatment.— (a) Prophylactic. —As, in the vast majority of cases, 
eclampsia is preceded by premonitory symptoms, its prophylaxis is in 
many ways more important than its actual cure, and is identical with that 
recommended for pre-eclamptic toxemia (p. 595). Indeed, the chief 
aim in treating the latter condition is to prevent the possible outbreak 
of eclampsia. Hence the necessity of regular and frequent examinations 
of the urine, blood pressure determinations, and weighings, and the 
immediate institution of appropriate treatment and diet as soon as 
symptoms appear, which indicate that the eliminative processes are at 
fault. By the employment of these precautionary measures, and by 
promptly inducing premature labor in those cases which do not improve, 
or which become progressively worse under treatment, the frequency 
of eclampsia will be greatly diminished and many valuable lives saved. 
At present, however, despite all we can do, eclampsia will still occur, 
and sometimes even in patients who apparently have responded most 
satisfactorily to prophylactic treatment. 

We have become convinced that prophylactic treatment, while pro¬ 
ductive of untold good, is not invariably successful or always applicable; 
and that those who teach that eclampsia is always a preventable af¬ 
fection, and that its occurrence indicates neglect on the part of the 
obstetrician, take too extreme a view and have been led astray by their 
enthusiasm. 

(5) Curative .—As has already been indicated, the curative treatment 
of eclampsia must remain empirical and unsatisfactory until its actual 
cause has been discovered. Consequently, although no unanimity exists 
among authorities as to the best course to pursue, it may be said that 
two diametrically different methods of treatment are advocated—radical 
and conservative. The proponents of the former insist that the essential 
feature is to empty the uterus by operative means as soon after the first 


ECLAMPSIA 


623 


convulsion as possible, while the advocates of the latter claim that this 
is not only unnecessary, but is actually harmful. 

The plea for radical treatment is based upon the notoriously pool- 
results which followed purely medicinal treatment in the past, as well 
as upon the fact that improvement frequently follows the termination 
of pregnancy. The conservative school, on the other hand, argues that 
the results following radical treatment have not been satisfactory, but 
are definitely inferior to those obtained by Stroganoff (1899) by means 
of profound narcosis, and by Tweedie and his followers (1903) by 
eliminative means. Generally speaking, it may be said that during the 
first fifteen years of the past quarter century radical treatment was 
predominant, whereas during the last ten years conservative treatment 
lias found more and more advocates. Personally, I have followed the 
same general tendency, and now practice a degree of conservatism, which 
I should have considered reprehensible earlier in my career. 

In considering the treatment, I shall outline in the first place what 
is now done in my service, then I shall consider how this practice differs 
from that employed in the past, and finally I shall attempt to explain 
why the changes have been instituted. 

The patient should be in a hospital if possible, as the facilities for 
treatment in a well-regulated service are greatly superior to those in 
even the most comfortable home. She should be placed in a quiet, 
darkened room and care should be taken that she is disturbed as little 
as possible. A competent nurse should be in attendance, who should 
not leave the patient alone until she has definitely come out of coma. 
Immediately after being put to bed, one-quarter grain of morphia is 
administered hypodermically, and the necessary examinations made. 
A second dose of morphia may be given when required, but not more 
than one half grain should be used during the first twenty-four hours. 
It comatose, the patient should be turned on one side and the foot of 
the bed elevated, so as to permit the ready escape of mucus and other 
fluid from the mouth. If it collects, in spite of this precaution, it 
should be swabbed out by the nurse. 

If a second convulsion occurs, venesection should be done, and the 
blood pressure noted every few minutes during its course. The blood 
should be allowed to flow until 1,000 cubic centimeters have been with¬ 
drawn, or until the blood pressure falls to 100 millimeters. Provided 
the blood pressure is properly controlled, the condition of the pulse 
offers no contra-indication. Indeed, it is sometimes observed that vene¬ 
section acts most beneficially when the pulse is weak and thready. In 
many instances, no further convulsions occur, and, if labor has already 
set in, the process goes on to a happy termination. If, however, labor 
has not supervened, it occasionally happens that following the venesection 
the eclampsia becomes arrested, the threatening symptoms disappear, 
and the pregnancy continues for several days or weeks, when the patient 
falls into labor spontaneously. Such an outcome represents the so-called 
intercurrent eclampsia of Lichtenstein, and was noted in 41 of his 255 
cases of antepartum eclampsia. 

If the patient is conscious she should be encouraged to drink large 




624 


THE TOXEMIAS OF PREGNANCY 


quantities of water, but if unconscious nothing should be given by mouth 
for fear of producing aspiration pneumonia. If the patient cannot drink 
on account of coma or lack of desire, 500 cubic centimeters of five per 
cent, glucose solution should be given intravenously, and repeated in 
twelve hours. In either event, as soon as the patient regains conscious¬ 
ness, fluids should be forced, and she should be encouraged to drink three or 
four liters of milk or water for each of the first few days of the puerperium. 

If the case is progressing satisfactorily there should be no thought 
of emptying the uterus until the cervix has become fully dilated, when 
anesthesia should be induced by gas or ether, and delivery completed 
by forceps or version, as seems most expedient. 

If, however, the convulsions and coma continue, and the cervix has 
become dilated to five centimeters in diameter, dilatation may be com¬ 
pleted by Harris’s manual method, and the child delivered by podalic 
version. This, however, represents our nearest approach to accouchement 
force, as we have learned by disastrous experience that any attempt at 
forcible dilatation of the cervix is not to the advantage of the patient. 

Generally speaking, cesarean section should be undertaken only in 
the presence of such disproportion or other condition as would indicate 
its performance irrespective of the existence of eclampsia, and with the 
understanding that it is resorted to solely on that account, and not with 
the idea of curing the eclampsia. As will be shown below, all recent 
stastistics indicate that it adds to the gravity of the prognosis. Conse¬ 
quently, I hold that its employment is not justified in the treatment of 
eclampsia, although it is sometimes indicated as a prophylactic procedure 
in women suffering from fulminating pre-eclamptic toxemia, in whom 
it is feared that eclampsia will supervene before the induction of labor 
can be effected by the usual methods. In postpartum eclampsia the 
same treatment applies, except, that when venesection is done, the amount 
of blood lost during the third stage should be taken into consideration. 

In connection with treatment, several important points concerning 
the general care of the patient should be mentioned. For example, if 
she is very restless or excitable between the convulsions, a few whiffs 
of ether or gas should be given before undertaking any manipulation, 
such as a vaginal examination, the administration of a hypodermic in¬ 
jection, catheterization, etc. On the other hand, the administration of 
an anesthetic for the purpose of controlling or shortening a convulsive 
seizure, is probably useless; but if it is done, ether should be employed 
instead of chloroform, as the latter is supposed to increase the tendency 
toward hepatic necrosis. Moreover, during the attack it is very important 
that a folded towel, a piece of thick rubber tubing, or a clothes-pin 
should be placed between the teeth for the purpose of avoiding injury 
to the tongue. If the bowels have not moved recently, one or two drops 
of croton oil in a tea-spoonful of sweet oil or two ounces of Epsom 
salts may be given by mouth, or if the patient is unconscious the croton 
oil alone may be placed upon the back of the tongue, or the salts may 
be given by stomach tube after that organ has been washed out. 

Twenty years ago the treatment would have been quite different, as 
delivery would have been effected as soon as possible after the first 




ECLAMPSIA 


625 




convulsion, the method employed varying with the condition of the 
cervix. After delivery, the patient would have been placed in a hot 
pack, with the idea of eliminating some of the toxic material along with 
the sweat; every attempt would have been made to stimulate diuresis 
by giving copious salt solution infusions under the breasts; and finally 
if recovery did not promptly ensue a few hundred cubic centimeters of 
blood would have been withdrawn. In other words, we formerlv effected 
delivery at almost any cost, placed great reliance upon the efficiency of 
sweating, administered salt solution subcutaneously, and employed vene¬ 
section as a last resort. 

Why have we changed? In the first place, we have gradually learned 
that forced delivery was occasionally the direct cause of the death of the 
patient, while in other cases it did not seem rational to subject a seriously 
ill woman to a radical operative procedure, unless assured of its necessity. 
In the second place, the results obtained by StroganofTs method caused 
us to take stock of what we were doing. The hot pack was abandoned 
for the reason that chemical analysis of the sweat showed that it con¬ 
sisted practically only of water, and contained but an insignificant 
fraction of excrementitious material, and, furthermore, because we gradu¬ 
ally gained the impression that the edema served some protective purpose, 
as experience taught us that patients did better when it was present 
than in its absence. Subcutaneous salt infusions have been abandoned 
for two reasons: First, since we have learned that there is an actual 
retention of sodium chlorid in the body, it does not seem rational 
to add to it; and, second, that glucose solution acts just as efficiently 
as a diuretic, and possesses the additional advantage that it enables us 
to introduce into the patient a small amount of an easily assimilable 
foodstuff. Finally, we learned if venesection is to be efficacious that it 
should be in considerable amount, and occasionally it results in as com¬ 
plete disappearance of the symptoms as if delivery had been effected. 

Such changes were only gradually put into practice, and sometimes 
in a halting manner, but we gradually gained the impression that after 
adopting them the patients did better and the duration of the attacks 
was lessened. Consequently, we became more and more conservative, 
with the result that when we tabulated our results in 1922, we found 
that they had improved by one-third, as shown in the following table: 


Table Showing Results of Treatment by Radical and Conservative 
Methods at the Johns Hopkins Hospital. 



Radical Treatment, 

1916-1911 

Conservative Treatment, 
1912-1922 • 


Cases 

Deaths 

% 

Cases 

Deaths 

% 

Antepartum and 
intrapartum 

85 

21 

24.7 

92 

12 

13 

Postpartum 

25 

4 

16 

23 

5 

21.7 

Total. 

110 

25 

22 

115 

17 

14.8 









































626 


THE TOXEMIAS OF PREGNANCY 


In other words, in antepartum and intrapartum eclampsia, conservative 
treatment has decreased the mortality almost by one-half—24.7 to 13 
per cent., while in the postpartum variety, in which the question of rapid 
delivery does not arise, it has remained practically unchanged. 

That others have obtained similar results is shown by the figures 
of Engelmann and Lichtenstein. The former went through a similar 
change during the ten years ending 1916, and reported a mortality of 
26, 13.6 and 6.7 per cent., according as he employed radical, transitional 
or conservative therapy respectively; while the latter, in the cases of 
ante- and intrapartum eclampsia treated between 1901 and 1911, and 
1911 and 1921, reported a mortality of 16.7 and 9.4 per cent., re¬ 
spectively. 

Unfortunately, however, the matter of treatment is not so simple, 
as the Stroganoff and Dublin methods apparently give as good, and 
possibly better, results, and yet are based upon diametrically opposite 
principles. For this reason, each will be briefly outlined. Stroganoff 
lays great stress upon following his directions in the most minute de¬ 
tails, which are as follows: 

When first seen morphia 14 grain, 

After one hour, chloral hydrate 30 grains in 200-250 c.cin. 

of saline solution by rectum, or in 100 c.cm. 

of milk bv mouth. 

%/ 

After 3 hours, morphia 14 grain 

After 7 ‘ ‘ chloral hydrate grains 30 

After 13 “ “ “ “20 

After 21 “ “ “ “20, 

and later every eight hours. 

Chloroform is administered to control the convulsions, cardiac stimulants 
are employed, delivery is not effected until after the cervix has become 
fully dilated, and if more than three convulsions occur 400 cc. of blood 
is withdrawn. Stroganoff has collected 2,208 cases treated by this 
method in various clinics with a mortality of 9.8 per cent., and reports 
that in 230 patients whom he treated personally it was only 1.7 per 
cent. 

On the other hand, Fitzgibbon and Solomons report 204 cases 
treated by the Dublin method with a mortality of 10.3 per cent. 

•—the lowest in the British Isles. In this method stress is laid upon 
starvation, stomach lavage, bowel lavage and the submammary infusion 
of sodium bicarbonate solution. Epsom salts are given after the gastric 
lavage, and large quantities of sodium bicarbonate solution are used 
for flushing the bowels. Morphia, chloral, chloroform and venesection 
are not employed, and delivery is effected only after the cervix has 
become completely dilated. 

Accordingly, it seems that Lichtenstein and ourselves obtain rela¬ 
tively good results with free venesection, Stroganoff possibly better re¬ 
sults with sedatives and scanty venesection, while the Dublin School 
obtains equally good results with eliminative treatment, without either 
sedatives or venesection. In the present state of our knowledge, it is 





ECLAMPSIA 


627 


impossible to state which of us is correct, or whether all of us are wrong, 
but one thing stands out clearly, and that is that the best results are 
obtained by conservative treatment, and not by those who lay stress 
upon the earliest possible delivery, without regard to the condition of 
the cervix. 

Four important facts emerge from Eden’s analysis of the British 
cases, as follows: 1, that the general mortality is unnecessarily high; 
2, that the best results are obtained in Dublin; 3, that the mortality 
is relatively low in the mild cases and high in the severe cases of eclamp¬ 
sia, irrespective of the method of treatment; and, 4, that in both groups 
the highest mortality follows the employment of cesarean section and 
accouchement force. It is my conviction that, excepting accouchement 
force, cesarean section represents the most dangerous method of treating 
eclampsia, and that resort to this spectacular method of delivery, by 
those who do not appreciate its dangers, has led to the unnecessary 
death of many women, and the same may be said of vaginal hysterotomy 
or vaginal cesarean section. That I do not stand alone in this opinion 
is shown by the fact that Peterson and Eardley Holland found that 
the mortality of cesarean section for this indication was 25.8 per cent, 
in this country and 32 per cent, in Great Britain. Consequently, the 
sooner the obstetrician and surgeon recognizes the fact the better it will 
be for their patients. 

In conclusion, a few words will be said concerning a number of 
procedures whose employment is not recommended for the reason that 
they have been tested and found wanting, or else evidence concerning 
their value has not been adduced. 

Thyroid extract has been advocated by Nicholson, who advises that 
70 to 80 grains be given daily during the attacks. It was used by Sturmer 
in a series of 41 cases with 5 deaths. Since other therapeutic measures 
were employed as well, it is impossible to judge of its efficiency. In 
the few instances in which it was used in my clinic favorable results 
were not obtained. 

The use of veratrum viride, which is highly praised by many 
American writers, has never appealed to me, and Stunner's statistics 
from the East India Medical Service, where it was used for twenty 
years, show a maternal mortality of 45 per cent. After reading the 
enthusiastic report of Mangiagalli, and of Cragin and Hull concerning its 
merits, I felt that I was perhaps wrong in rejecting it. Accordingly, in a 
series of cases I gave it to every other patient, while the alternate patient 
was treated in identically the same manner except for the veratrum. 
While the hypodermic administration of 5 to 10 minims of the fluid 
extract, repeated if necessary, undoubtedly leads to a marked slowing 
of the pulse, and occasionally to an almost alarming fall in blood pres¬ 
sure, the patients did neither better nor worse than those who did not 
receive it. For this reason I abandoned its use. 

Engelmann in 1911 reported good results in 14 cases of eclampsia by 
the intravenous injection of 0.2 to 0.3 gram of hirudin (leech extract) 
in a liter of Finger’s solution. The remedy is employed with the idea 
that it will inhibit coagulation of the blood and thus prevent thrombosis. 








628 


THE TOXEMIAS OF PREGNANCY 


Engelmann recommends its employment particularly in severe cases of 
postpartum eclampsia, but admits that further experience will be neces¬ 
sary before its merits can be fully determined. 

The intravenous injection of serum from normal pregnant women 
has been recommended with the idea that it may furnish some antibody, 
which should be normally present, and thus neutralize the supposititious 
eclamptic toxin. With somewhat the same idea, Blair Bell has recom¬ 
mended the transfusion of blood from normal individuals, but proof 
of the efficiency of either suggestion has not yet been adduced. 

In 1904 Kronig employed lumbar puncture in eclampsia with bene¬ 
ficial results. He found the cerebrospinal fluid under a considerably 
increased tension, and noted apparent improvement following the with¬ 
drawal of from 20 to 10 degrees cubic centimeters. The procedure has 
been rather extensively employed, and Spillman, after recently reviewing 
the literature upon the subject, found that in 25 out of 68 cases it was 
followed by cessation of the convulsions. As this corresponds to a 
mortality of 62 per cent., it cannot be regarded as a hearty recommenda¬ 
tion. From what 1 have seen, it appears to be unnecessary in mild, and 
useless in severe cases. 

Renal decapsulation was performed in a case of eclampsia by Edebohls 
in 1902, although it had previously been suggested by Sippel. The former 
considered that it acted by relieving the intrarenal tension, and thereby 
favored the resumption of urinary section. The subject has been re¬ 
viewed by Chamberlent and Pousson, Pinard, and Sippel, who believe 
that it is of value in cases of total suppression following delivery, and 
may be employed as a last resort. 

In view of the marked liability of eclamptic women to infection, all 
operative procedures must be conducted in the most rigidly aseptic man- , 
ner, particular care being taken to avoid the contamination of the vagina 
and the hands of the operator by faecal material. 


PRESUMABLE TOXEMIAS 

I nder this heading are included a number of conditions occurring 
during pregnancy and the puerperium, concerning whose nature and 
origin we are as yet ignorant, but which are most readily explained by 
supposing that they are dependent upon some variety of auto-intoxication. 

Certain psychoses clearly belong in this category. In some cases 
they are definitely associated with pre-eclamptic toxemia, and disappear 
as the underlying condition becomes ameliorated. 

I recall one patient who, during the later months of pregnancy, 
suffeied from delusions of persecution. At such times large amounts 
of albumin were piesent in the urine, while the urea output was greatly 
diminished. Sweat baths were repeatedly followed by an immediate 
improvement in the condition of the urine, after which the mental 
condition became normal, the delusions reappearing, however, within 

a few days, to again disappear under the same treatment. Complete 
recovery followed delivery. 






PRESUMABLE TOXEMIAS 


629 


Again, some cases occur in which the most careful study of the urine 
fails to reveal the slightest evidence of toxemia, and yet the mental 
derangement promptly disappears upon the employment of milk diet, 
rest, and eliminative treatment. On the other hand, most of the psy¬ 
choses occurring during the puerperium are to be regarded as manifesta¬ 
tions of infection, and are directly due to the absorption of poisonous 
materials generated by infectious microorganisms. 

Many cases of peripheral neuritis should also be regarded as due to 
toxemia, and we have already referred to its frequent association with 
the vomiting of pregnancy. Lindemann, in a fatal case, clearly showed 
that the nerve lesions were associated with degenerative changes in both 
the liver and kidneys. On the other hand, as far as can be ascertained 
by clinical observation, such an association is absent in other cases, 
but even here it is permissible to believe that the underlying factor must 
be an auto-intoxication of some character. 

Likewise certain non-contagious skin diseases, such as impetigo and 
herpes gestationis, are susceptible of a similar explanation, and sometimes 
yield to a milk diet and proper eliminative measures after obstinately 
resisting the usual local and medicinal treatment. Excessive salivation, 
which sometimes occurs in pregnant women, is also probably due to a 
toxemia of some kind, as is particularly shown in the cases associated 
with vomiting of pregnancy. At the same time, intense salivation may 
occur without such an association, and may resist all remedial measures 
until the patient is placed in bed and put upon a rigorous milk diet. 

Dirmoser, Sondern, and others have insisted that auto-intoxication 
from the intestinal tract plays a prominent part in the production of 
many of the abnormalities of pregnancy; and the former holds that 
most cases of vomiting during pregnancy are due to it, and, therefore, 
considers that the presence of indican, indol, skatol, and ethereal sul¬ 
phates in the urine affords strong evidence in favor of such a view. 
Glaessner has shown that profound symptoms of auto-intoxication can 
be produced experimentally in dogs by reversing the direction of in¬ 
testinal peristalsis. In such cases marked changes are manifested in 
the urine, which consist particularly in a distortion of the relative pro¬ 
portions of its nitrogenous constituents. 

Occasionally women suffer from asthma in every pregnancy, but at 
no other time; and there is a certain amount of evidence available which 
points to its being due to an underlying toxemia. Thus, I have seen 
several patients in whom the condition was not relieved by medicinal 
treatment, yet it yielded readily to milk diet and eliminative measures; 
though at no time could changes be demonstrated in the urine in support 
of its toxemic origin. On the other hand, in one of my cases the con¬ 
dition was associated with pre-eclamptic toxemia, and disappeared only 
after the induction of premature labor. 

Occasionally conditions occur during the puerperium which can only 
be explained upon the assumption of an underlying toxemia. Thus, I 
have seen three women, whose urine was apparently perfectly normal, 
go through an uneventful pregnancy and labor, and on the second or 
third day of the puerperium pass into a comatose condition, which per- 


630 


THE TOXEMIAS OF PREGNANCY 


sisted for several days, but from which they slowly recovered. In each 
instance a careful chemical and microscopical examination of the urine 
was made, but failed to reveal any abnormality. In one of these patients 
there was slight jaundice, and the clinical symptoms were such that 
one was forced to consider the possibility of chloroform poisoning. 
As all of the patients recovered, it is naturally impossible to speak 
positively as to the nature of the condition, but, notwithstanding 
the negative results obtained by the study of the urine, it is difficult 
to explain its production by any other supposition than that of a pro¬ 
found toxemia. This being the case, it must be admitted that we 
occasionally have to deal with conditions which in all probability are 
toxemic in origin, but concerning whose nature we are as yet absolutely 
ignorant. 


LITERATURE 

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Bar. Est-il demontre que l’eclampsie est une maladie microbienne? L’ob- 
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Les reins des eclamptiques. L ’obstetrique, 1903, viii, 193-215. 

Bar et Guyeisse. Lesions du foie et des reins chez les eclamptiques et les foetus 
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Beatty. A Case of Acute Yellow Atrophy of the Liver. Medical Record, 1895, 
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Benthin. Kohlehydratstoffwechsel in der GraviditaL Monatsschr. f. Geb. u. 
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Blumreich und Zuntz. Exp. und kritische Beitrage zur Pathogenese der 
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Bouchard. Lemons sur 1’auto-intoxication. Paris, 1887. 

Bouffe de Saint Blaise. Lesions anat. que l’on trouve dans l’eclampsie. These 
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Foie et eclampsie puerperale. Annales de gyn. et d’obst., 1891, xxxv, 48. 

Quelques cas d’acces eclamptiques sans albuminurie. Annales de gyn. et. obst., 
1900, liv, 76-77. 

Buttner. Untersuclnmgen iiber die Nierenfunktion bei Schwangerschaftsniere 
und Eklampsie. Arch. f. Gvn., 1906, lxxix, 421-478. 

Cassamayor. Contribution a 1 ’etude de l’eclampsie puerperale d ’apres une statis- 
tique de la Clinique de 1872-1892. These de Paris, 1S92. 

Chamberlent. Toxicite de serum maternal et foetal dans un cas d ’eclampsie puer¬ 
perale. Archives eliniques de Bordeaux, 1894, 271-284. 

Recherches exp. anat. path, sur les causes de la mort du foetus dans 1 ’eclampsie 
puerperale. Nouv. arch, d’obst. et de gyn., 1895, 175. 

Charpentier. Eclampsie sans albuminurie. Traite pratique des accouchements. 
Paris, 1883, i, 699. 

Copeman. A Novel Treatment of Obstinate Vomiting in Pregnancy. Brit. Med. 
Jour., 1875, i, 637-638. 

Cragin and Hull. The Treatment of Eclampsia. J. Am. Med. Assn., 1911, lvi, 
5-11. 

Davis and Whipple. Liver Regeneration Following Chloroform Injury as In¬ 
fluenced by Various Diets. Arch. Int. Med., 1919, xxiii, 711. 

Delmer. Contribution a 1 ’etude de 1 ’eclampsie vitulaire. These de Paris, 1904. 





LITERATURE 


631 


Delore et Rodet. Memoire sur 1 ’etiologie bacterienne de 1 ’eclampsie. Resume 
dans l’arch. de tocologie, 1884, ii, 921. 

Dienst. Kritische Studien iiber die Pathogenese der Eklampsie, Archiv f. Gym, 
1902, lxv, 369-464. 

Exp. Studien iiber die aetiologische Bedeutung des Fibrinferments u. Fibrinogen 
fur d. Eklampsie. Archiv f. Gyn., 1912, xcvi, 43-170. 

Zur Eklampsiefrage. Zeitschr. f. Geb. u. Gyn., 1920, lxxxii, 102-135. 

Dirmoser. Der Vomitus gravidarum pernieiosus. Wien, 1901. 

Dublin. Mortality among Women from Causes Incidental to Child-bearing. 
Am. J. Obst., 1918, lxxviii, 20-37. 

Duhrssen. Ueber Eklampsie, Thiel II. Archiv f. Gyn., 1893, xliii, 49-161. 

Duncan. Clinical Lecture on Hepatic Diseases in Gyn. and Obst. London Med. 
Times and Gazette, 1879, i, 57-59. 

Duncan and Harding. A Report on the Effect of High Carbohydrate Feeding 
on the Nausea and Vomiting of Pregnancy. Jour. Can. Med. Assoc., 1918, 
viii, 1057-1069. 

Edebohls. Surgical Treatment of Bright’s Disease. New York, 1904. 

Eden. A Commentary on the Reports Presented to the British Congress of 
Obstetrics and Gynecology, June 29, 1922. Jour. Obst. and Gyn. Brit. 
Emp., 1922, xxix, 386-401. 

Emge. Further Observations on Acidosis in Pregnancy (with special reference 
to the CO o method of Van Slyke). Am. Jour. Obst., 1918, lxxvii, 813-821. 

Engelmann. Ueber die Behandlung der Eklampsie mittels intravenose Hirudin- 
injektionen. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 640-664. 

Hat die Einhaltung der mittleren Linie bei der Behandlung der Eklampsie 
noeh Berechtigung? Zentralbl. f. Gyn., 1920, 1113-1128. 

Ewing. The Path. Anatomy and Pathogenesis of the Toxaemia of Pregnancy. 
Am. Jour. Obst., 1905, li, 145-155. 

The Pathogenesis of the Toxaemia of Pregnancy. Am. Jour. Med. Sci., 1910, 
cxxxix, 828-846. 

Ewing and Wolf. The Clinical Significance of the Urinary Nitrogen, etc. Am. 
Jour. Obst., 1907, lv, 289-336. 

Fahraens. The Suspension Stability of the Blood. Stockholm, 1921. 

Fehling. Die Pathogenese and Behandlung der Eklampsie im Lichte der heutigen 
Anschauungen. Volkmann’s Sammlung klin. Yortrage, N. F., 1899, Nr. 248. 

Fieux. Sero-therapie. Annales de gyn. et d’obst., 1912, ix, 718-725. 

Flexner. Thrombi Composed of Agglutinated Red Blood Corpuscles. Univ. of 
Pennsylvania Med. Bulletin, 1902, No. 9. 

Freund und Mohr. Pathogenese der Eklampsie. Berliner klin. Wochenschr., 
1908, xlv, Nr. 40. 

Futh u. Lockemann. Ueber den Nachweis von Fleischmilchsaiire in der Zerebro- 
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Gessner. Die badische Eklampsie-statistik, etc. Zentralbl. f. Gyn., 1922, 1914- 
1918. 

Glaessner. Experimentelles iiber die Obstipation. Wiener klin. Wochenschr., 
1904, xvii, 1205-1206. 

Goldsborough and Ainley. The Renal Activity as Revealed by the Phenol-sul- 
phone-phthalein Test. Jour. Am. Med. Assn., 1910, lv, 24. 

Goldzieher. Allg. Pathologic und path. Anatomie der puerperalen Eklampsie. 
Lubarsch-Ostertag: Ergebnisse der Allg. Path. u. path. Anat., 1919, xix 
I Abt., 117-158. 

Grafenburg. Die anaphylaktische Beziehungen zwischen Mutter and Kind. Zeit¬ 
schr. f. Geb. u. Gyn., 1911, lxix, 270-282. 




632 


THE TOXEMIAS OF PREGNANCY 


Guggisberg. Exp. Untersuchungen fiber die Toxikologie der Placenta. Zeitschr. 
f. Geb. u. Gyn., 1910, lxvii, 84-112. 

Haffner. Les soi-disant infarctus placentaires et leur relation avec 1 ’albuminurie 
de la grossesse. Gyn. et Obst., 1921, iii, 81-89. 

Halbertsma. Ueber die iEtiologie der Eklampsia puerperal is. Volkmann ’s 
Sammlung klin. Vortrage, 1884, Nr. 212. 

Harding and Watson. Further Observations on the Use of Carbohydrates in 
the Nausea and Vomiting of Pregnancy. Lancet, 1922, ii, 649-654. 

Healy and Kastle. Parturient Paresis (Milk Fever) and Eclampsia. Jour, of 
Infectious Diseases, 1912, x, No. 2. 

IIeinrichsdorff. Die anat. Veranderungen der Leber in der Schwangerschaft. 

Zeitschr. f. Geb. u. Gyn., 1912, lxx, 620-665. 

IIelouin. Contribution a 1’etude du diagnostic de l’hepato-toxemie gravidique. 
These de Paris, 1899. 

Hinselmann. Die Capillarstromung bei der Eklampsie. Archiv f. Gyn., 1923, 


cxvi, 443-505. 


Hirst. The Intravenous Use of Corpus Luteum Extract in Nausea of Pregnancy. 
Jour. Am. Med. Assn., 1921, lxxvi, 772-773. 

Hofbauer. Zur Klarung der Eklampsiefrage. Zentralbl. f. Gvn., 1921, 1797-1810. 

Graviditats-toxikosen. Zeitschr. f. Geb. u. Gyn., 1908, Ixi, 258-271. 

Holland. The Results of a Collective Investigation into Caesarean Sections 
Performed in Great Britain and Ireland from the Year 1911 to 1920 In¬ 
clusive. Jour. Obst. and Gyn. Brit. Emp., 1921, xxviii, 358-446. 

Ingerslev. Beitrag zur Albuminurie wahrend der Schwangerschaft, der Geburt 
und der Eklampsie. Zeitschr. f. Geb. u. Gyn., 1881, vi, 171-212. 

Jardine and Kennedy. Symmetrical Necrosis of the Cortex of the Kidney Asso¬ 
ciated with Puerperal Eclampsia. Trans. Edinburgh Obst. Soc., 1912-1913, 


xxxviii, 158-183. 


Job. Contributions a 1 ’etude de la myelite et des polynevrites au coins des vomis- 
sements toxiques d’origine gravidique. Annales de gyn. et d’obst., 1911, viii, 
129-146. 


Johnstone. Exp. Study of the Anaphylactic Theory of the Toxaemia of Preg¬ 
nancy. J. Obst. and Gyn. Brit. Emp., 1911, xix, 253-260. 

Jurgens. Fettemboli und Metastasen von Leberzellen bei Eklampsie, etc. Berliner 
klin. Woehenschr., 1886, xxiii, 519. 

Kaltenbach. Ueber Hyperemesis gravidarum. Zeitschr. f. Geb. u. Gyn., 1891, 
xxi, 200-208. 

Kehrer. Untersuchungen iiber den Kalkgehalt des Blutes, besonders in Schwanger¬ 
schaft, Geburt und Wochenbett, und bei Nephritis und Eklampsie. Arch, 
f. Gyn., 1920, cxii, 4S7-523. 

Killian. Significant Chemical Changes in the Blood in the Toxemias of Preg¬ 
nancy. Appleton, 1922, p. 183. 

Klebs. Multipel Leberzellen-thrombose. Ziegler’s Beitrage, 1888, iii, 1-30. 

Knapp. Ueber puerperale Eklampsie und deren Behandlung. Berlin, 1900. 

Kollmann. Zur JEtiologie und Therapie der Eklampsie. Zentialbl. f. Gyn., 1897, 
xxxi, 341-346. 

Kronig. Ueber Lumbarpunktion bei Eklampsie. Zentralbl. f. Gyn., 1904, xxviii, 
1153-1156 and 1511-1512. 

Landsberg. Untersuchungen von Harn und Blut bei Eklamptisehen. Zeitschr. 
f. Geb. u. Gyn., 1913, lxxiii, 234-265. 

Leathes. Acidosis in Pregnancy. Proc. Royal Soc. Med., 1908, March. 

LeMasson. Les icteres et les eoliques hepatiques chez les femmes en etat du puer- 
peralite. These de Paris, 1898. 






LITERATURE 


633 


Lever. Cases of Puerperal Convulsions, with Remarks. Guy’s Hospital Reports, 
1843. 

Lichtenstein. Im Kampfe gegen die placentare Theorie der Eklampsieatiologie. 
Zentralbl. f. Gyn., 1909, xxxiii, 1313-1325. 

Zur Klinik, Therapie u. iEtiologie der Eklampsie. Arehiv f. Gyn., 1911, xcv, 
183-368. 

Weitere Erfalirungen mit der abwartenden Eklampsiebehandlung. Monatsschr. 
f. Geb. u. Gyn., 1913, xxxviii, 152-165. 

Zehn Jahre geburtshulflich abwartender Eklampsiebehandlung. Zentralbl. f. 
Gyn., 1922, 5-34. 

Liepmann. Zur .ZEtiologie u. Therapie der Eklampsie im Wochenbett. Zentralbl. 
f. Gyn., 1906, xxx, 693-698. 

Zur iEtiologie der Eklampsie. Miinchener med. Wochenschr., 1905, Nos. 15 and 
51. 

Lindemann. Zur path. Anat. des unstillbarcn Erbrechens der Schwangeren. Zen¬ 
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Longridge. The Relation of the Alterations in the Ammonia Coefficient to the 
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Losee and Van Slyke. The Toxemias of Pregnancy. Am. J. Med. Sciences, 
1917, cliii, 94-100. 

Lubarscii. Die Puerperal-eklampsie. Ergebmsse der allg. Path, und path. Anat., 
1896, i, 113-134. 

Ludwig und Savor. Experimentelle Studien zur Pathogenese der Eklampsie. Mo¬ 
natsschr. f. Geb. u. Gyn., 1895, i, 447-473.ffl 

Lwow. Hyperemesis gravidarum. Deutsche Medicinal-Zeitung, 1900, xxi, 1013- 
1015. 

McNalley and Dieckmann. Hemorrhagic Lesions of the Placenta and Their 
Relation to White Infarct formation. Am. J. Obst. and Gyn., 1923, v, 55-66. 

McPherson. A Study of Eclampsia. J. Amer. Med. Assn., 1907, liii, 1362-1363. 

A Consideration of the Pregnancy Toxemia Known as Eclampsia. Am. J. 
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McQuarrie. Isoagglutination in Newborn Infants and Their Mothers, etc. 
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Mangiagalli. Yeratrum viride in eclampsia. British Med. Jour., 1908, Sept., 
19. 

Mayer. Ueber die Beziehungen der Geburtsliilfe u. Gynekologie zum Krieg und 
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Miller. The Relation of Albuminuric Retinitis to the Toxemias of Pregnancy. 
Am. J. Obst., 1915, lxxii, 253-269. 

Muller. Die Kapillaren der menschlichen Korperoberflache. Stuttgart, 1922. 

Murray. Nature of Eclampsia. J. Obst. and Gyn. British Emp., 1910, xviii, 225- 
245. 

Nash and Benedict. The Ammonia Content of the Blood, and its Bearing on 
the Mechanism of Acid Neutralization in the Animal Organism. J. Biol. 
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Nicholson. Case of Puerperal Eclampsia Treated by Large Doses of Thyroid 
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Obata. On the Nature of Eclampsia. Jour, of Immunology, 1919, iv, 111-139. 

Olshausen. Ueber Eklampsie. Volkmann’s Sammlung klin. Vortrage, N. F., 
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Opie. Zonal Necroses of the Liver. Jour. Medical Research, 1904, xii, 147-167. 

Pearce and Jackson. Experimental Liver Necrosis. Studies from the Bender 
Hygienic Laboratory, 1907, iv, 35-51. 







634 


THE TOXEMIAS OF PREGNANCY 


Pels Leusden. Beitrage zur path. Anatomie der Puerperal-eklampsie. Virchow’s 
Archiv, 1895, cxlii, 1-45. 

Pick. Ueber Hyperemesis gravidarum. Volkmann’s Sammlung klin. Vortrage, 
N. F., 1902, Nrs. 325-326. 

Pilliet et Letienne. Lesions du foie dans l’eclampsie avec ictere. Nouv. arch, 
d’obst. et de gyn., 1889, iv, 312-367. 

Pinard. De la decapsulation renale dans l’eclampsie. Annales de gyn. et d’obst., 
1906, 2me S., iii, 193. 

Des vomissements de la gestation. Annales de gyn. et d’obst., 1909, N. S. vi, 
385-399. 

Plass. The Significance of the Non-coagulable Nitrogen Coefficient of the Blood 
Serum. Am. J. Obst., 1915, lxxi, 608-615. 

Variations in the Distribution of the Non-Protein Nitrogenous Constituents of 
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Prutz. Ueber das anat. Verhalten der Nieren bei der Puerperal-eklampsie. 
Zeitschr. f. Geb. u. Gyn., xxiii, 1892, 1-52. 

Ueber Eklampsie. Vereins-Beilage der deutsch. med. Wochenschr., 1897, 194. 

Quincke. Acute Leberatrophie. Nothnagel ’s Specielle Path. p. Thr., 1899, xviii, 
294-315. 

Rayer. Traite des maladies des reins. Paris, 1839. 

Reinburg. Les acces dits eclamptiques. These de Paris, 1905. 

Riviere. Patliogenie et traitement de 1 ’eclampsie. Paris, 1889. 

Rolleston. Symmetrical Necrosis of the Cortex of the Kidney Associated with 
Suppression of Urine in Women Immediately after Delivery. Lancet, 1913, 
Oct. 26. 

Rosenau and Anderson. Further Studies upon Anaphylaxis. Hygienic Lab. Bull., 
1908, No. 45, p. 55. 

Rosenstein. Ueber Eklampsie. Monatsschr. f. Geburtsk., 1864, xxiii, 413-430. 

Schickele. Die Schwangerschafts-toxemie. Archiv. f. Gyn., 1917, cvii, 209-250. 

Schuppel. Ein Fall von doppelseitiger totale.r Nierenrinden Nekrose bei Eklamp¬ 
sie. Archiv f. Gyn., 1914, ciii, 243-271. 

Schild. Sechs Falle von Nitrobenzol-vergiftung. Berliner klm. Wochenschr., 
1895, xxxii, 187-189. 

Schmid. Eklampsie ohne Krampfe. Zeitschr. f. Geb. u. Gyn., 1911, Ixix, 143-164. 

Schmorl. Path. anat. Untersuchungen fiber Puerperal-eklampsie. Leipzig, 1893. 

Zur Lehre von der Eklampsie. Archiv f. Gyn., 1902, lxv, 504-529. 

Schonfeld, Die Toxizitat der Plazentalipoide und ihre Rolle in der Etologie 
der Puerperaleklampsie. Deut. med. Wochenschr., 1921, xlvii, 270. 

Exp. Untersuchungen fiber die Toxizitat von Placentalipoiden, mit Bezug auf 
die Etiogenese der Puerperaleklampsie. Arch, ffir Gyn., 1922, cxv, 80-125. 

Seitz. Innere Sekretion und Schwangerschaft. Leipzig, 1913. 

Sellheim. Die mammare Theorie fiber die Entstehung der Eklampsiegiftes. Zen- 
tralbl. f. Gyn., 1910, 1609-1615. 

Sippel. Die Nephrotomie bei Anurie Eklamptischer. Zentralbl. f. Gyn., 1904, 
xviii, 1341. 

Sitzenfrey. Eklampsie im 6sten Schwangerschaftsmonat bei Blasenmole, etc. 
Zentralbl. f. Gyn., 1911, 343-346. 

Slemons. Eclampsia without Convulsions. Bull. Johns Hopkins Hospital, 1907, 
xviii, 448-455. 

Is Albuminuria Likely to Recur with Succeeding Pregnancies? Am. J. Obst., 
1913, lxvii, 849-860. 

Slemons and Bogert. The Uric Acid Content of Maternal and Fetal Blood. 
J. Biol. Chem., 1917, xxxii, 63-69. 




LITERATURE 


635 


Solomans. The Results of the Treatment of Eclampsia by the Dublin Method. 
Jour. Obst. & Gyn., Brit. Emp., 1922, xxix, 416-425. 

Spiegelberg. Ein Beitrag zur Lehre von der Eklampsie. Ammonia im Blute. 
Archiv. f. Gyn., 1870, i, 383-391. 

Spillman. Lumbar Puncture in the Treatment of Eclampsia. Am. J. Obst. and 
Gyn., 1922, iv, 568-571. 

Stadie and Van Slyke. The Etfect of Acute Yellow Atrophy on Metabolism and 
on the Composition of the Liver. Arch. Int. Med., 1920, xxv, 693-794. 

Stone. Toxaemia of Pregnancy. Amer. Gyn., 1903, iii, 518-550. 

Strauss. The Toxaemia of Pregnancy. Amer. Jour. Obst., 1905, lvii, 145, 164. 

Stroganoff. Ueber die Behandlung der Eklampsie. Zentralbl. f. Gyn., 1901, xxi, 
1309-1312. 

My Improved Method of the Prophylactic Treatment of Eclampsia. J. Obst. 
and Gyn. Brit. Emp., 1923, xxx, 1-31. 

Sturmer. Forty-one Cases of Eclampsia Treated by Thyroid Extract. Trans. 
London Obst. Soc., 1904, xlvi, 126. 

Talbot. Focal Infection and Its Relation to Obstetrics. J. Am. Med. Assn., 1920, 
lxxiv, 874-878. 

Tarnier et Chamberlent. Note relative a la recherche de la toxicite du serum 
sanguin dans deux cas d ’eclampsie. Comptes rendus de la soc. de biol., 1892, 
iv, 179-182. 

Thierfelder. Acute Atrophy of the Liver. Ziemssen’s Cyclopedia of the Prac¬ 
tice of Medicine. Amer. ed., 1880, ix, 242-305. 

Thies. Zur Aetiologie der Eklampsie. Archiv. f. Gyn., 1910, xcii, 513-536. 

Titus, Hoffmann and Givens. The Role of Carbohydrates in the Treatment of 
Toxemias of Early Pregnancy. J. Am. Med. Assoc., 1920, lxxiv, 777-783. 

Titus and Givens. Intravenous Injections of Glucose in Toxemia of Pregnancy. 
J. Am. Med. Assn., 1922, lxxviii, 92-98. 

Underhill and Rand. Peculiarities of Nitrogenous Metabolism in Pernicious 
Vomiting of Pregnancy. Archives of Int. Med., 1910, v, 61-91. 

Van der Velde. Eklampsie puerperalis tardiforma. Ref. FrommeUs Jahres- 
berieht, 1897, 752. 

Varo. Krieg und Eklampsie. Zentralbl. f. Gyn., 1920, 523-526. 

Vassale. Ref. FrommeUs Jahresbericht, 1905, xix, 404. 

Veit. Ueber Albuminurie in der Schwangerschaft. Berliner klin. Wochenschr., 
1902, xxxix, 512-540, Nrs. 22 and 23. 

Die Verschleppung der Chorionzotten. Wiesbaden, 1905. 

Wallis. The Toxemia of Pregnancy with Special Reference to Certain Renal 
Function Tests in Diagnosis. Jour. Obst. and Gyn. Brit. Emp., 1921, xxviii, 
3-22. 

Ward. The Relation of the Thyroid Gland and Thyroidism to the Toxemia of 
Pregnancy. Surg., Gyn. and Obst, 1909, ix, 617-633. 

Warnekros. Kriegskost und Eklampsie. Zentralbl. f. Gyn., 1916, 897-902. 

Weiss. Beobachtung u. mikrophotographische Darstellung der Haut-kapillaren 
am lebenden Menschen. Deutsches Archiv f. klin. Med., 1916, cxix, 1-138. 

Whipple. A Test for Hepatic Injury; Blood Lipase. Bull Johns Hopkins 
Hospital, 1913, xxiv, 357-362. 

Whipple and Sperry. Chloroform Poisoning, etc. Bull. Johns Hopkins Hospital, 
1909, xx, 278-289. 

Williams. Pernicious Vomiting of Pregnancy. Bull. Johns Hopkins Hospital, 
1906, xvii, 71-92. 

Toxsemic Vomiting of Pregnancy. Am. Jour. Med. Sci., 1906, cxxxii, 343-354. 

Further Contributions to Our Knowledge of the Pernicious Vomiting of Preg¬ 
nancy. J. Obst. and Gyn. Brit. Emp., 1912, xxii, 245-265. 




636 


THE TOXEMIAS OF PREGNANCY 


Winckel. Lehrbuch der Geburtshiilfe, 1893, II. Aufl., 536-547. 

Winckler. Beitrag zur Lehre von tier Eklampsie. Virchow's Archiv, 1898, cliv, 
187-233. 

Winter. Zur iEtiologie der Hyperemesis gravidarum. Zentralbl. f. Gyn., 1907, 
1497-1504. 

Young. .Etiology of Eclampsia and Albuminuria. J. Obst. and Gyn. Brit. Einp., 
1914, xxvi, 1-28. 

Young and Miller. The Etiology of Eclampsia and the Pre-eclamptic State. 
Brit. Med. Jr., 1921, (1) 486-490. 

Zanfrognini. Ref. Frommel’s Jahresbericht, 1905, xix, 804. 

Zangemeister. Dei Eklampsie eine Hirndruckfolge. Zeitschr. f. Geb. u. Gyn., 
1917, lxxix, 124-174. 

Der Hydrops gravidarum, sein Verlauf und seine Beziehungen zur Nephropathie 
und Eklampsie. Zeitschr. f. Geb. u. Gyn., 1919, lxxxi, 491-558. 

Zinsser. Ueber die Nierenfunktion Eklamptischer. Zeitschr. f. Geb. u. Gyn., 
1912, lxx, 201-221. 

Zweifel. Zur Aufkliirung der Eklampsie. Archiv f. Gyn., 1904, lxxii, 1-97, and 
1905, lxxvi, 536-585. 

Das Gift der Eklampsie u. ihre Consequenzen fUr die Beliandlung. Miinchener 
med. Wochenschr., 1906, liii, 297-299. 

Ueber die Beliandlung der Eklampsie. Monatsschr. f. Geb. u. Gyn., 1913, 1-22. 

Zweifel, E. Wirkt fotales Serum art-fremd auf das Muttertier, 1920. 


CHAPTER XXVII 


COMPLICATIONS DUE TO DISEASES AND ABNORMALITIES OF THE 

GENERATIVE TRACT 

DISEASES OF THE VULVA AND VAGINA 

Varices. —Varicose veins sometimes appear in the lower part of the 
vagina, but are more common around the vulva, where they may attain 
considerable proportions and give rise to a sensation of weight and dis¬ 
comfort. Treatment has practically no effect upon the local condition. 
In rare instances the varices may rupture during pregnancy, though this 
accident is more frequently observed at the time of labor, when profuse 
and sometimes fatal hemorrhage may result if appropriate surgical treat¬ 
ment is not available. 

Inflammation of Bartholin’s Glands. —Pyogenic microorganisms may 
gain acess to Bartholin’s glands and give rise to abscess formation. In 
this event the labium majus on the side affected becomes swollen and 
painful, and incloses a collection of pus. Most often the infection is 
gonorrheal in origin, though other bacteria are sometimes associated 
with the gonococcus. Aside from the pain and discomfort, this com¬ 
plication may be the starting-point of a puerperal infection. For these 
reasons, whenever a labial abscess develops during pregnancy it should 
be opened and drained; or, better still, the entire pus sac should he 
excised. Owing to the increased vascularity incident to the inflammatory 
process, as well as to pregnancy, enucleation is sometimes accompanied 
by considerable loss of blood, and is not always easy. 

Relaxation of the Vaginal Outlet. —Even in nulliparous women the 
congestion incident to pregnancy frequently causes the anterior or pos¬ 
terior vaginal wall to protrude through the vulva as a redundant mass; 
while in multiparous women, particularly when the outlet is torn or 
relaxed, a distinct cystocele or rectocele may result. This condition is 
generally associated with dragging pains in the hack and lower abdomen, 
and may interfere with locomotion. It is not amenable to treatment 
during pregnancy, though the symptoms may be temporarily relieved 
by rest in bed. 

Vaginitis. —This complication has already been considered in Chap¬ 
ter XXV, under the heading of Gonorrhea. 

Colpohyperplasia Cystica. —This rare condition, first described by 
Winckel, is characterized by the presence in the vaginal mucosa of 
numerous small cavities filled with clear fluid or gas and forming ele¬ 
vations upon its surface. x41though not amenable to treatment during 
pregnancy, it usually disappears soon after childbirth. The researches 

637 






638 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


of Lindenthal render it probable that the lesion is sometimes due to 
infection with Bacillus aero genes capsulatus, and Jaeger has been able 
to produce it experimentally in animals. 

DISEASES OF THE CERVIX 

Cervical Endometritis. —Gonorrheal infection of the cervical canal is 
frequently observed during pregnancy, the most prominent symptom 
being a profuse and persistent leukorrhea. The treatment has already 
been considered. 

Carcinoma. —About once in 2,000 cases, according to Sarwey, but less 
frequently in this country, pregnancy is complicated by carcinoma of 
the cervix. It is most common in women between the thirtieth and 
fortieth years of life, two thirds of the cases collected by Sarwey having 
occurred within this decade, while the youngest patient was twenty-six 
years old. 

In the majority of instances the condition has existed before con¬ 
ception, but it may make its appearance during pregnancy. A bloody, 
f'oul-smelling vaginal discharge is suggestive of malignant disease, but 
unfortunately the early stages are often unaccompanied by symptoms, 
and may escape detection unless a vaginal examination is made for 
some other reason, when an indurated and excavated ulceration of the 
cervix is discovered. 

Pregnancy tends to bring about rapid growth and extension of a 
preexisting carcinoma. On the other hand, the malignant disease in¬ 
fluences pregnancy very unfavorably, abortion being noted in 30 to 40 
per cent, of the cases. Furthermore, if the patient reaches full term 
the dangers of labor are greatly increased. In the first place, the 
presence of the ulcerating crater affords opportunity for the access of 
pyogenic bacteria to the uterine cavity; while the cervix may be so 
indurated by carcinomatous infiltration that dilatation becomes impos¬ 
sible and spontaneous rupture of the lower uterine segment becomes 
imminent, unless suitable operative measures are undertaken to prevent 
it. In other instances, the cervix may be lacerated and give rise to 
profuse hemorrhage. In 603 cases collected by Sarwey the mortality at 
the time of labor, or during the puerperium, was 43.3 per cent., 8 per 
cent, of the patients dying undelivered. 

The treatment of pregnancy complicated by carcinoma of the cervix 
differs according to the period at which the diagnosis is made and the 
extent to which the disease has progressed. If the condition has not 
extended beyond the cervix, immediate abdominal hysterectomy should 
be performed in the hope of effecting a permanent cure, without regard 
for the chances of the foetus. Sarwey has reported 26 vaginal operations 
without a death, during the first half of pregnancy; but during that 
period I consider that a radical abdominal operation is preferable. On 
the other hand, if the case is inoperable, gestation should be allowed to 
continue in the interests of the child, and cesarean section performed 
at term, if the condition of the cervix is such as to render spontaneous 
delivery improbable. 





DEVELOPMENTAL ABNORMALITIES OF THE UTERUS 


639 


The treatment of inoperable cases bv means of radium raises another 
question. If it is thought advisable to employ it, the uterus must be 
emptied as a perliminary procedure, since the action of the radium will 
inevitably lead to the death of the child. In such circumstances cesarean 
section may be indicated even though the child is not viable. 


DEVELOPMENTAL ABNORMALITIES OF THE UTERUS 


Abnormalities in the development or fusion of one or both mullerian 
ducts may result in malformations, which sometimes possess an obstet¬ 
rical significance. Various degrees of mal¬ 
formation—from an almost total absence of 
the uterus on the one hand to its duplica¬ 
tion on the other (uterus didelphys)—are 
encountered. The accompanying diagrams 
(Figs. 467 to 473) give an idea of the nature 
of the more important varieties. 

Pregnancy may be associated with any 
one of these malformations provided an 
ovum be cast otf from the ovaries and no 
serious obstacle be opposed to the upward 
passage of the spermatozoa and their subsequent union with it. 

Pregnancy in the Rudimentary Horn of a Double Uterus. —In this 
condition the course of pregnancy is exposed to serious modifications. 



Fig. 467. —Diagram of Uter¬ 
us Unicornis (Kehrer). 



. .1-,' : 
1 1 ' 


Fig. 468. — Uterus Pseudodidelphys 
(Kehrer). 



Fig. 469. — Uterus Bicornis Duple x 
(Kehrer). 



(Kehrer). 



Fig. 471. —Uterus Bicornis Subseptus 
(Kehrer). 


We owe to Mauriceau the first description of a case of this character, 
but since his time many examples have been lepoited. 

In 78 per cent, of the '84 cases collected from the literature by 
Kehrer in 1900, the proximal end of the rudimentary horn did not 













640 


COMPLICATIONS DUE TO 


DISEASES OF GENERATIVE 


TRACT 


communicate with the uterine cavity, so that in them pregnancy must 
have followed external migration of the spermatozoa or of the fertilized 
ovum. 

The development of pregnancy in a rudimentary horn is associated 



Fig. 472. —Uterus Bicornis Unicollis Fig. 473. —Uterus Bicornis Unicollis 

(Kehrer). with Rudimentary Horn (Kehrer). 


with the formation of a decidua in the non-pregnant horn, as well as 
by a marked increase in its size. Unless there is free communication 
between the two horns, which is but rarely the case, a pregnancy in 
this situation is a very serious occurrence, since normal delivery is im- 
possible. If the muscular tissue of the rudimentary horn is poorly 



Fm. 4/4. Pregnancy IN a Rudimentary Left Uterine Horn. External 

Migration of Ovum (Kelly). 


developed, as is usually the case, spontaneous rupture occurs within the 
first four months and leads to the death of the patient from intraperi- 
toneal hemorrhage. This result was noted in 87, 47.6, and 5.5 per cent, 
of the cases collected by Sanger, Kehrer, and Beckmann, respectively, 
in 1884, 1900, and 1911. The marked improvement is attributable to 
greater accuracy in diagnosis and more frequent recourse to operative 










DEVELOPMENTAL ABNORMALITIES OF THE UTERUS 


641 


interference. On the other hand, if the muscular tissue is abundant 
the pregnant horn may hypertrophy normally, and the pregnancy go on 
to term. If not removed by operative means, the foetus may be grad¬ 
ually eliminated by suppurative processes, or be converted into a litho- 
pedion. 

The existence of pregnancy in a rudimentary horn can occasionally 
be recognized during the early months, a positive diagnosis having been 
made in 20 per cent, of Kehrer’s cases. When a tumor corresponding 
in size to the duration of pregnancy can be detected alongside of what 
appears to be the slightly enlarged uterus, this condition should always 
be thought of. In differentiating it from a tubal pregnancy, it is 
important to remember that the round ligament is felt coming off from 
the distal side of the tumor instead of from its proximal or uterine 
portion, as in the latter condition. In the later months, a diagnosis is 
usually not made until false labor sets in at term. In other cases this 
does not occur and the child dies; but, in either event, no abnormality 
is suspected until one attempts to empty the uterus, when it is found 
that its cavity is empty and that the child lies in a sac to one side of 
it, which must represent either a pregnant tube or a rudimentary horn. 
A satisfactory differentiation can always be made by determining the 
location of the round ligament as described above. 

Treatment .—If the condition be diagnosticated, treatment consists 
in promptly opening the abdomen and amputating the pregnant horn. 
This operation was first performed by Sanger in 1884, and has since 
been repeated on many occasions with constantly improving results, 
Kehrer, and Wells having reported 44 cases up to 1900, and Beckmann a 
large series in 1911, with a mortality of 13.4 and 4.3 per cent., respec¬ 
tively. Too frequently, however, the first suggestion of the existence of 
the abnormality is afforded by the symptoms of intraperitoneal hemor¬ 
rhage, when the operation is undertaken in the expectation of find¬ 
ing a ruptured extra-uterine pregnancy. 

Pregnancy in Uterus Unicornis.—Occasionally only one horn of the 
uterus is developed, the opposite tube and ovary being lacking or arising 
from the lower portion of the uterus. In such cases pregnancy usually 
pursues an uneventful course, and the abnormality is only accidentally 
recognized at the operating or autopsy table. 

Pregnancy in Uterus Bicornis.—When the two horns of the uterus 
are well developed, but no connection exsits between them, as in uterus 
didelphys, or when they are partly fused, as in the various varieties of 
uterus bicornis, pregnancy may occur in either horn. In the very rare 
instances in which a twin pregnancy is observed, the two products of 
conception may occupy the same horn, although now and again an embryo 
has been found in each. 

When pregnancy occurs in one horn of a bicornuate uterus, the 
other undergoes sympathetic hypertrophy and a distinct decidua is 
formed in its cavity. Ordinarily there is no interference with the course 
of pregnancy, and spontaneous labor may be looked for. Much more 
rarely the non-pregnant horn may block the pelvic cavity, and give rise 
to dystocia, similar to that produced by tumors of other origin. In a 




642 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


case observed in my clinic and reported by Bettman, the non-pregnant 
horn obstructed the pelvic cavity and gave rise to rupture of the uterus. 
Van der Velde made a critical study of the subject in 1915, and has 
collected from the literature a series of cases requiring cesarean section 
or some other radical intervention. 

Miller in 1922 analyzed the clinical histories of 54 cases reported 
in the literature. That the abnormality does not interfere with the 
possibility of conception is shown by the fact that 31 of the 34 married 
women conceived and had 67 pregnancies. It does, however, predispose 
toward the occurrence of abortion and premature labor, as only 61 per 
cent, of the pregnancies went to term. When difficulty was encountered* 
at the time of labor, it was usually due to mechanical interference by 
the enlarged non-pregnant horn. 

The diagnosis is usually not made, as in the majority of cases spon¬ 
taneous labor occurs at term; although Halban states that a pathog¬ 
nomonic sign is afforded by the palpation of the vesicorectal ligament, 
as a band extending upward from the bladder over the top of the uterus, 
and lying between the two round ligaments. Our own patient had 
given birth to 8 children without any suspicion of the existence of the 
deformity having arisen. Sometimes the existence of a double vagina 
or a double cervix puts one on the alert. The former may occur with 
a normal uterus, whereas the latter condition almost invariably indicates 
the existence of a double uterus. When there is only a single cervix, 
as in uterus bicornis unicollis, the condition always escapes observation, 
unless the patient is subjected to examination at an early period of 
pregnancy, and the depression noted between the two halves of the 
uterus gives a clue to the true state of affairs. 


DIVERTICULA FROM UTERINE CAVITY 

Freund and Schickele have reported instances in which the pregnancy 
developed in a diverticulum from the uterine cavity, so that the foetus 
lay in a sac surrounded by uterine muscle, and connected with the main 
uterine cavity only by a narrow passage. It is apparent that it would 
be difficult to recognize such a condition clinically, unless the fingers 
were introduced into the uterine cavity, and it is likewise clear that it 
may give rise to serious complications at the time of labor. 


DISPLACEMENTS OF THE UTERUS 

Anteflexion. —Exaggerated degrees of anteflexion are frequently ob¬ 
served in the early months of pregnancy, but are usually without sig¬ 
nificance. In the later months, particularly when the pelvis is markedly 
contracted or the abdominal walls are very lax, the uterus may fall 
forward, the sagging being occasionally so exaggerated that the fundus 
lies considerably below the lower margin of the symphysis pubis. Even 
in less marked instances of the so-called pendulous abdomen, the patient 
may complain of various annoyances, more especially of exhaustion on 


643 


DISPLACEMENTS OF THE UTERUS 


exertion and dragging pains in the back and lower abdomen. Ameli¬ 
oration ot symptoms frequently follows the wearing of a properly fitting 
abdominal supporter. 



Anteversion of the pregnant uterus is occasionally observed in pa- 
tients who have previously been subjected to operative procedures for the 
relief of symptoms incident to retroflexion of the uterus, particularly 
after vaginal fixation, less frequently after an improperly performed 
ventrosuspension, and now and again after shortening of the round 
ligaments. The condition is accompanied by marked discomfort during 
piegnancy, and at the time of labor may give rise to serious dystocia, 
which will be considered in Chapter XXXII. 

Reti ©displacement of the Pregnant Uterus. —Retroflexion and retro¬ 
version of the uterus are frequently observed in 11011 -pregnant women, 
and usually cause 


more or less incon¬ 
venience, though 
occasionally the 
condition may 
exist for vears 
without any ab¬ 
normal manifesta¬ 
tion. In women 
who have never 
borne children the 
abnormal position 
of the cervix is 
supposed to render 
difficult the access 
of spermatozoa to 
the uterine cavity, 
so that the possi¬ 
bility of concep¬ 
tion is consider¬ 
ably diminished. 

In parous women, 
on the other hand. 

this influence is less pronounced, but pregnancy, when it occurs, is prone 
to early interruption. The abortion is usually due to inflammatory or 
trophic changes in the endometrium, which are in great part dependent 
upon abnormalities in the circulation of the displaced uterus. 

In the vast majority of cases of pregnancy complicated by retro- 
displacements, the uterus was already out of place before conception; 
although the abnormality may arise during gestation, when it would 
seem that the enlarged and softened organ is unable to retain the 
position which it maintained without difficulty when it was of normal 
size and consistency. 

Pregnancy is more frequently complicated by retroflexion than by 
retroversion, though it is said that the latter tends to give rise to serious 
symptoms at an earlier period. In either case several eventualities are 


Fig. 475. —Sacculation of Retroflexed Pregnant Uterus 

(Oldham). 















644 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


possible: the displacement may undergo spontaneous reduction without 
any interruption to pregnancy; abortion may occur; or, if neither takes 
place, the uterus may become incarcerated in the pelvic cavity and 
serious consequences follow. 

If the displaced uterus is not adherent, spontaneous reduction usually 
occurs during the third month. This is rendered possible by an eccentric 
hypertrophy, owing to which the anterior wall undergoes more rapid 
distention than the posterior, and emerging above the superior strait 
eventually draws up the rest of the organ. After the fundus has once 
passed the promontory of the sacrum there is no fear of a recurrence of 
the condition. Moreover, spontaneous reduction is not wholly out of the 
question, even when adhesions exist, since they often become stretched 
and occasionally disappear without any treatment. Retroflexion offers 
better prospects than retroversion; indeed, as Diihrssen and Keitler have 



pointed out, when the latter condition is marked spontaneous restitution 
is almost impossible, for the reason that the cervix rises above the 
symphysis pubis, while the fundus is held back by the promontory of 
the sacrum. 

In rare instances, when the fundus is firmly adherent, pregnancy 
may remain uninterrupted for a long while. This prolongation is ren¬ 
dered possible by the hypertrophy occurring almost entirely in the ante¬ 
rior wall of the uterus, while the posterior wall fills out the pelvic cavity, 
and forms a sac in which one pole of the foetus is retained. This 
so-called sacculation of the uterus has been described in detail by Oldham, 
Diihrssen, and others. Owing to the abnormal position of the cervix 
and the fact that the presenting part lies far below it, serious difficulties 
are to he expected at the time of labor, which will he considered in 
Chapter XXXII. 

Abortion is common in pregnancies complicated by retrodisplace- 













DISPLACEMENTS OF THE UTERUS 


645 


ments. It usually occurs in the course of the third month, when the 
growing uterus pretty well fills the pelvic cavity and, becoming irritated 
by the pressure to which it is subjected, begins to contract, and thus 
brings about the expulsion of its contents. This termination is particu¬ 
larly likely to occur when the sacrum possesses an exaggerated vertical 
concavity, since the projecting promontory opposes a serious obstacle 
to spontaneous restitution. 

If pregnancy continues and the displacement is not reduced in the 
natural course of events, or as the result of manipulations on the part 
of the physician, the uterus will continue to increase in size until it 
completely fills the pelvic cavity and, being unable to free itself, becomes 
impacted, and we have what is known as incarceration. Untoward 
effects, due to pressure, come on sooner in retroversion than in retro¬ 
flexion, for the reason that in the former the cervix compresses the 
lower portion of the bladder at an earlier period. Incarceration is ac¬ 
companied by characteristic symptoms, the woman complaining of pain 
in the lower portion of the abdomen and back, and disturbances in the 
functions of the urethra, bladder, and rectum. As the pelvis becomes 
more and more filled by the growing uterus, the pressure upon the neck 
of the bladder and urethra becomes so pronounced as to cause retention 
of the urine with consequent over-distention. Reed, however, holds that 
the ischuria is not merely mechanical, but is due to compression of 
the pelvic ganglia by the body of the uterus, with resulting paralysis 
of the motor nerves of the bladder. But, whatever its cause, when the 
retention has reached a certain limit, the overstretched viscus squeezes 
out small amounts of urine at frequent intervals, but never empties 
itself —paradoxicial incontinence. If the condition is not soon relieved, 
the symptoms become more intense, cystitis develops, and the bladder 
walls become thick and edematous, the urine becomes bloody, and eventu¬ 
ally gangrene may result, necrotic portions of the lining membrane 
of the bladder being cast off and finally expelled through the urethra 
with severe cramplike pains. In other cases the weakened walls of the 
bladder are unable to withstand the distention and rupture occurs, 
followed by a fatal peritonitis. 

Occasionally, as the result of the pressure to which it is subjected, 
the nutrition of the uterus may so suffer that it offers little resistance 
to bacterial invasion, when it becomes densely adherent to the surround¬ 
ing parts, while now and again the organ may be forced down and 
out of the pelvic cavity and emerge through tin 3 vulva or anus. In 
some cases the rectum is compressed to such an extent that defecation 
becomes impossible and gangrene results. Ileus, however, is an exceed¬ 
ingly rare complication. 

Gottschalk found that the following were the most frequent causes 
of death in 67 cases reported in the literature up to 1894: 


Peritonitis of vesical origin. 17 

Uremia. 16 

Rupture of the bladder. 11 

Septicemia of vesical origin. 4 

Gangrene of the bladder. 3 









646 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


The possibility of a retroflexed pregnant uterus should always be 
suspected when a woman in the early months of pregnancy complains 
for any length of time of frequent and painful micturition, especially 
if there is a history of antecedent uterine trouble. Incontinence of 
urine during the first half of pregnancy is a most suggestive sign, and 
always calls for a thorough vaginal examination. "W ith the bimanual 
method, the soft body of the uterus will be found occupying the pelvic 
cavity, while the cervix is forced up against the symphysis or lies abo\e 
it, according as one has to deal with a retroflexion or retroversion. 
It should be remembered that a pregnant tube lying behind the uterus 
may give somewhat similar signs, and this possibility should be borne 
in mind until careful examination has shown that the enlarged uterus 
does not lie in front of the soft mass. 

Treatment .—If the retroflexion is detected in the first three months 
of pregnancy, bimanual reposition of the uterus should be attempted, 
aided by traction upon the cervix by means of a tenaculum or bullet 
forceps. After reposition has been effected, a properly fitting Smith- 
Hodge pessary should be introduced. On the other hand, if these simple 
maneuvers fail, the patient should be left alone until well on into the 
third month, in the hope that spontaneous reduction may occur. If 
this has not taken place by that time, a more determined effort at 
replacement should be made, with the patient in the knee-chest position. 
If this proves unsuccessful, reduction can usually be effected by bimanual 
manipulations under anesthesia. 

When dense adhesions are present, various procedures have been 
recommended—the forcible attempt to break them up under anesthesia, 
attempts to loosen them by means of a succession of vaginal packs, the 
colpeurynter, or the “watch-spring” pessary, from the use of which 
Sinclair has reported excellent results. Generally speaking, these methods 
are not to be recommended, and, if the uterus cannot be replaced under 
anesthesia, laparotomy may be performed, the adhesions separated under 
the guidance of the eye, and the uterus placed in normal position. Such 
radical interference, however, is rarely necessary, but in several of my 
cases it was followed by satisfactory results. 

On the other hand, if the patient has not been seen until after 
symptoms of incarceration have supervened, prompt treatment is impera¬ 
tive. The bladder should be immediately emptied. This cannot always 
be accomplished with the ordinary female catheter on account of the 
elongation of the urethra and neck of the bladder resulting from the 
displacement (Fig. 478), so that in many cases a flexible rubber catheter 
must be employed. Its introduction may often be facilitated by making 
traction upon the cervix with a tenaculum. After the bladder has been 
emptied, attempts should be made to replace the uterus—under anes¬ 
thesia, if necessarv. But if this cannot be effected, most authors advise 
emptying it immediately by dilating the cervical canal. T believe that 
better results will be obtained in such cases by laparotomy, or by a modi¬ 
fied hysterotomy, in which the posterior instead of the anterior, portion of 




DISPLACEMENTS OF THE UTERUS 


647 


the lower uterine segment and cervix is incised. On the other hand, 
if symptoms of infection or gangrene are present, laparotomy, as recom- 
i men ded b} Lobenstein, should not be done, since the weakened and 
necrotic bladder may be injured, or dense adhesions may be encountered 
which have formed over the uterus, practically shutting it off from the 
abdominal cavity and rendering the freeing of it almost impossible. 
Undei these ciicumstances the obstetrician should content himself with 
: emptying the uterus per vaginam in the most conservative manner, and 
then rely upon palliative 
treatment. 

Lateral Displacement 
of the Pregnant Uterus. 

—Slight degrees of lat¬ 
eral displacement of the 
uterus during pregnancy 
are relatively frequent, 
but usually have no effect 
upon its course and do 
not give rise to symp¬ 
toms. It should, how- 
E ever, be borne in mind 
that in the early months 
i similar conditions are 
sometimes mistaken for 
tubal pregnancy. 

Prolapse of the Preg¬ 
nant Uterus. —Impregna¬ 
tion in a totally pro¬ 
lapsed uterus is very rare 
on account of the difficul- 
| ties attending a success- 
; ful coitus, but is com- 
paratively frequent if the 
prolapse is only partial. 

In such cases the cervix, 
and occasionally a por¬ 
tion of the corpus, may Fig. 477. —Prolapsed Pregnant Uterus (Wagner) 
protrude to a great or 

lesser extent from the vulva during the early months, but as pregnancy 
progresses the body of the uterus gradually rises up in the pelvis, and 
draws the cervix up with it, so that as soon as it has passed beyond 
the superior strait, prolapse is no longer possible. On the other hand, 
if the uterus retains its abnormal position, symptoms of incarceration 
appear during the third or fourth month, and abortion is the inevitable 
result, there being no cases on record in which pregnancy has progressed 
to term with the uterus outside of the body. 

If there is a tendency towards prolapse during pregnancy, the uterus 
should be replaced and held in position by a suitable pessary. If, how¬ 
ever, the pelvic floor he too relaxed to permit its retention, the patient 


















648 


COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


should be kept in a recumbent position as far as possible until after the 
fourth month. When the cervix reaches to or slightly protrudes from the 



vulva, the greatest cleanliness is necessary, as instances of fatal infection 
have been reported as occurring even without any internal examination. 
If the uterus persistently lies outside of the vulva and cannot be re¬ 
placed, it should be emptied of its contents. 

When the vaginal outlet is markedly relaxed, the congested anterior 

or posterior vaginal walls sometimes prolapse during pregnancy, although 

__ the uterus may still 

retain its normal 
position. This con¬ 
dition may give rise 
to considerable dis¬ 
comfort and inter¬ 
fere with locomo¬ 
tion. It is not 
amenable to treat¬ 
ment until after de¬ 
livery. At the time 
of labor these struc¬ 
tures may he forced 
down in front of 
the presenting part 
and interfere with 
its descent. When 
this occurs they 
should be carefully 
cleansed and pushed 
back over it. 

In rare instances 
a hernial protrusion 
may occur through 
the vagina, the an¬ 
terior or posterior 

Fig. 478. —Pregnancy in Horn of Uterus Contained in forming part 

Inguinal Canal (Eisenhart). ot the sac. Such 


a vaginal enterocele 


may form a tumor of considerable size tilled with intestines. Hirst 
has collected 27 instances from the literature. If the condition occurs 
during pregnancy, the protrusion should be replaced and the patient 
kept in the recumbent position. At the time of labor it may seriously 
interfere with the advance of the head. In such cases the mass should 
be pushed up if possible, and, when this cannot be done, it should be 
held out of the way as well as may be, and the head delivered past it. 

Hypertrophic Elongation of the Cervix.—An abnormally elongated 
cervix seriously interferes with the occurrence of conception, but, as a 
rule, does not complicate the course of pregnancy or labor. The canal 
usually becomes shorter and more dilatable as term is approached. 
In one of my patients the vaginal portion of the cervix in the early 











DISPLACEMENTS OF THE UTERUS 


649 


months was 5 centimeters in length and the external os protruded from 
the vulva, whereas later it had undergone marked softening and become 
reduced to normal dimensions, so that labor occurred spontaneously. 

Acute Edema of the Cervix.—In very rare instances the cervix, par¬ 
ticularly its anterior lip, may become acutely edematous during preg¬ 
nancy and attain such proportions as to protrude from the vulva. This 
condition is referable to an angioneurosis, and may disappear almost 
as suddenly as it developed. Jolly, in 1904, was able to collect 10 cases 
from the literature. 

Hernia.—Pregnancy occurring in women suffering from inguinal her¬ 
nia is not influenced by the condition, although, owing to the increased 



Fig. 479.—Hernia of Pregnant Uterus (Adams). 


intra-abdominal pressure, the previous defect may become aggravated. 
Generally speaking, the hernia should be treated palliatively by rest and 
the use of a truss, operative treatment being deferred until after delivery. 
Very exceptionally, the uterus may form part of the contents of an 
inguinal hernia, and, indeed, several cases are on record in which con¬ 
ception has occurred under such circumstances. Full literature upon 
the subject will be found in the articles of Adams and Eisenhart, the 
latter having reported a case in which one horn of a five months’ preg¬ 
nant bicornuate uterus occupied the right inguinal canal. 

Umbilical herniae are frequently noted during pregnancy, but are 
usually without effect upon the condition. During the early months the 
uterus is not in the neighborhood of the hernial opening, while later, 
when the fundus reaches its level, it is usually too large to gain access 
to it; but when the abdomen is markedly pendulous, such an occurrence 
is not beyond the range of possibility, and several such instances are on 















050 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


record. Much more common are the cases in which the cicatrix of an 
abdominal incision yields to the increased intra-abdominal pressure in¬ 
cident to pregnancy, and along the linea alba is formed a hernial sac 
into which the pregnant uterus often makes its way, being then covered 
merely by a thin layer of skin, fascia, and peritoneum. 

A similar condition is occasionally observed in women suffering from 
extensive diastasis of the recti muscles. Fig. 419 represents a patient in 
whom a hernia of this kind occurred suddenly during labor. Ordinarily, 
such herniae have no effect upon pregnancy, although they may add 
markedly to the discomfort of the patient. Temporary relief is frequently 
obtained by holding the uterus in its normal position by a properly 
fitting bandage. At the time of labor, owing to the loss of muscular 
tone in the abdominal walls, the second stage is liable to be prolonged, 
and the employment of forceps is often called for. Such herniae should 
be repaired during the later weeks of the puerperium. 


DISEASES OF THE DECIDUA 

In non-pregnant women the endometrium is frequently the seat of 
lesions which are grouped together clinically under the general heading 
of endometritis. Histological examination shows, however, that the term 
is usually a misnomer, as the changes are generally trophic rather than 
inflammatory in character, and in many instances merely represent 
phases of the menstrual cycle. The most important varieties are classi¬ 
fied as follows: 

Hyperplastic endometritis—general hyperplasia, localized hyperplasia, 
polypoid growths. 

Glandular endometritis—glandular hyperplasia. 

Interstitial endometritis—general hypoplasia. 

Acute and subacute endometritis—inflammatory changes. 

These conditions are prototypes of more or less similar lesions oc¬ 
curring in the decidua, except, of course, that the latter are modified 
by the histological characteristics incident to pregnancy. 

In the vast majority of inflammatory cases, as was first pointed out 
by Veit, the decidual affection represents the extension of a lesion already 
existing prior to pregnancy, conception occurring in a uterus affected 
by infective endometritis. In rare cases, however, the condition may 
originate during pregnancy. 

It is generally believed that endometritis is almost necessarily asso¬ 
ciated with sterility, the abnormal secretion of the uterine glands inter¬ 
fering with impregnation, and, even if conception occurs, the diseased 
mucosa does not offer a favorable nidus for the implantation of the ovum. 
Generally speaking, this belief is justified only when the endometrium 
is the seat of an acute inflammatory process, and every physician can 
recall instances in which sterility has persisted until more or less normal 
conditions were restored. On the other hand, slight degrees of chronic 








DISEASES OF THE DECIDUA 


651 




endometritis, or of hyperplastic conditions, do not, as a rule, interfere 





with conception. 

Diffuse Thickening of the Decidua.—Hegar, Kaltenbach, Kaschewa- 
rowa, and others have described a general hyperplasia of the decidua, in 
which the membrane, instead of becoming thinner, as is generally the 
case after the first few months, assumes unusual proportions. The 
condition frequently results in abortion, as a large part of the nutritive 
material intended for the foetus is diverted to nourishing the decidua. 
After abortion or labor, 
thickened decidua may 
cause abnormalities in 
the separation of the pla¬ 
centa. 

In other cases, the 
thickening is more or less 
localized— decidua poly- 
posa. In this affection, 
the characteristic feature 
consists in the projection 
of irregularly s h a p e d 
knoblike masses from the 
inner surface of the 
decidua. Virchow first 
described this condition 
as decidua tuberosa or 
polyposa, and considered 
it to be syphilitic in 
origin, which, however, 
is not always the case. 

Ahlfeld states that it is 
frequently observed, and 
Nyulasy of Melbourne 
has noted more than 100 
cases in his own practice. 

Bulius holds that it oc¬ 
curs but rarely, and I 

have never met with an Fig. 480. —Decidua Polypsa (Bulius). 


instance. 

Glandular Hyperplasia of the Decidua (Endometritis Decidua Gland¬ 
ularis) .—Occasionally marked hyperplasia of the glandular structures of 
the decidua is present, and is usually associated with persistence of the 
glandular ducts. This affection commonly manifests itself by a profuse 
secretion of clear fluid, which may dribble away as rapidly as it is 
produced, or be retained in the uterus to be suddenly discharged in 
large quantities at variable intervals— hydrorrhea gravidarum. The 
amount of fluid expelled varies considerably, though Ahlfeld has re¬ 
ported a case in which it exceeded 500 cubic centimeters on several 
occasions. This condition precludes the fusion of the decidua vera and 
reflexa, and therefore in the occasional instances in which it continues 








652 


COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


throughout pregnancy it must be assumed that these structures had 
failed to unite as usual. 


Since 1899 considerable discussion has arisen concerning the nature 
of hydrorrhea gravidarum. Stoeckel, Meyer-Ruegg, and other authorities 
believe that it does not result from changes in the decidua, but is due 




to premature rupture of the foetal membranes. The latter observer, 

in 1904, collected 15 cases 
from the literature in which 
a period varying from fifty 
to one hundred and twenty 
days had elapsed between the 
rupture of the membranes 
and the termination of preg¬ 
nancy. In such cases there 
occurs a constant trickling of 
amniotic fluid, and examina¬ 
tion of the placenta shows 
that the membranes have be- 

~ ^ come retracted about the 

Fig. 481.— Endometritis Decidua Cystica 

(Breus). maternal end of the cord, so 

that their cavity is far too 
small to inclose the foetus. Van der Hoeven inclines to the older view, 
and bases his belief upon the analysis of specimens of the fluid expelled, 
which differs from the liquor amnii in having a lower specific gravity and 
in not containing albuminous materials or urinary constituents. 

In rare cases the openings of the uterine glands may become occluded, 
small retention 
cysts being formed 
which project from 
the surface of the 
decidua, giving it a 
nodulated appear¬ 
ance. The affection 
has been described 
by Hegar, and 
Breus as endomet¬ 
ritis cystica. 

Atrophic Endo¬ 
metritis Decidua.— 

Under this heading 
Hegar, Ahlfeld, and 
others have de¬ 
scribed a disease in 
which large por¬ 
tions of the decidua vera and serotina undergo atrophic changes similar 
to those which occur normally in the portions corresponding to the lateral 
margins of the uterus. They offer no suggestion as to its etiology, but 
consider that it interferes with the nutrition of the ovum and is a fre¬ 
quent cause of abortion. It should be remembered, however, that the etio- 


Fig. 482.—Decidual Endometritis. X 280. 









DISEASES OF THE DECIDUA 


653 


logical significance of such conditions must be limited to the weeks 
immediately following implantation; as it often happens in the later 
months of pregnancy that the decidua basalis may become reduced to 
a fraction of a millimeter in thickness without interfering with the 
attachment of the placenta or with the nutrition of the foetus. 

Acute Endometritis Decidua.—Acute inflammatory lesions of the 
decidua frequently follow attempts at criminal abortion, though now 
and again they may occur without such a history, cases having been 
reported by Donat, Emanuel and Witkowsky, and others. Reference 
has already been made to the lesions of the endometrium associated 
with gonorrhea and occasionally with acute infectious diseases. 

In many instances I have been able to demonstrate the presence of 
cocci or bacilli in sections, and occasionally in cultures. These observa¬ 
tions prove beyond doubt the bacterial origin of the lesions, but it is 
usually difficult to decide whether the inflammatory process preceded, or 
was merely coincident with, the abortion. In these cases the decidua 
vera and basalis are thickened and their external surface covered with 
a yellowish purulent exudate. Under the microscope the tissue is found 
to be infiltrated with leukocytes, and presents the typical picture of 
acute inflammation, with here and there areas of necrosis. 

Maslowsky, Neumann and others have been able to demonstrate the 

I presence of gonococci in acute inflammation of the decidua; and it is 
probable that such conditions are quite common. 

The various forms of endometritis decidua complicating pregnancy 
are most important factors in the causation of spontaneous abortion, and 
the existence of some one of them should be suspected whenever the 
patient complains of a sensation of weight in the lower abdomen asso¬ 
ciated with a slightly blood-stained or dirty brownish discharge, particu¬ 
larly when there is a history of gonorrheal infection or of repeated 
abortions which were not associated with palpable lesions of the genera¬ 
tive tract. Furthermore, it is permissible to assume that the hypertrophic 
or atrophic abnormalities of the decidua may play a part in the pro¬ 
duction of placenta previa, by making it necessary for the organ to 
establish a wide area of attachment. 

Endometritis is not amenable to treatment during pregnancy. Should 
the patient present the slightest sign of its existence after abortion or 
childbirth, appropriate measures should be promptly instituted, since the 
condition frequently persists and may become seriously aggravated in a 
subsequent pregnancy. 

Metritis.—Unless it results from infection, metritis is a very rare 
complication of pregnancy, and when it exists was usually present before 
conception. It predisposes to abortion and is not amenable to treatment 
during pregnancy. 

Peri-uterine Inflammation.—when pregnancy occurs in women suf¬ 
fering from peri-uterine inflammation, considerable discomfort may re¬ 
sult from the stretching of old adhesions. Not uncommonly abortion 
results. Now and again the inflammatory changes undergo exacerbation 
during pregnancy, and may eventuate in abscess formation, which is 
accompanied by the usual symptoms of pelvic peritonitis. Very excep- 








654 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 


tionally rupture may occur and give rise to acute peritonitis, which can 
be successfully combated only by radical operative measures. 

Pregnancy Complicated by Tumors.—Pregnancy, is occasionally com¬ 
plicated by the presence of ovarian or uterine tumors. Although, as a 
rule, they do not materially affect its course, they frequently give rise to 
serious dystocia at the time of labor, and will therefore be considered 
in detail in Chapter XXXII. 


LITERATURE 

Adams. Hernia of the Pregnant Uterus. Amer. Jour. Obst., 1889, xxii, 225-246. 
Ahlfeld. Ueber Endometritis decidualis tuberoso-polyposa. Archiv. f. Gyn., 
1876, x, 168-176. 

Hydrorrhcea gravidarum. Endometritis atrophicans. Lehrbuch der Geb., II. 
Aufl., 1898, 253. 

Beckmann. Weiterer Beitrag zur Graviditat im rudimentaren Uterus-Horn. Zeit- 
schr. f. Geb. u. Gyn., 1911, lxviii, 600-639. 

Bettman. A Case of Labor in a Bicornuate Uterus. Bulletin Johns Hopkins Hosp., 
1902, xii, 57. 

Breus. Ueber cystose Degeneration der Decidua vera. Archiv. f. Gyn., 1882, xix, 
483-489. 

Bulius. Ueber Endometritis decidua polyposa et tuberosa. Munchener med. 
Wochenschr., 1896, Nr. 28. 

Donat. Endometritis purulenta in der Schwangerschaft. Archiv. f. Gyn., 1884, 
xxiv, 481-486. 

Duhrssen. Aussackungen, etc., der schwangeren Gebarmutter. Archiv. f. Gyn., 
1899, lvii, 70-223. 

Eisenhart. Fall von hernia inguinalis cornu dextri uteri gravidi. Archiv f. 
Gyn., 1885, xxvi, 439-459. 

Emanuel. Zur Lehre von der Endometritis in der Schwangerschaft. Zeitschr. f. 
Geb. u. Gyn., 1895, xxxi, 187-198. 

Emanuel und Witkowsky. Ueber Endometritis in der Graviditat. Zeitschr. f. 
Geb. u. Gyn., 1895, xxxii, 98-111. 

Gottsciialk. Zur Lehre von der Retroversio uteri gravidi. Archiv f. Gyn., 1894, 
xlvi, 358-383. 

Halban. Ein diagnostisches Zeichen fur Schwangerschaft in einem Uterus 
bicornis. Zentralbl. f. Gyn., 1904, 9-11. 

Hegar. Kysten-bildung in der Decidua. Monatsschr. f. Geburtsh., 1863, xxi, 
Supplement-Heft, 11. 

Die Driisen der Decidua und die Hydrorrhcea gravidarum. Monatsschr. f. 
Geburtsk., 1863, xxii, 429-451. 

Hegar and Maier. Beitrage zur Pathologie des Eies. Virchow’s Archiv, 1871, lii, 
161-192. 

Hirst. Vaginal Enterocele in Pregnancy and Labor. Trans. Amer. Gyn. Soc., 
1893, xviii, 351-357. 

Jaeger. Das Intestinalemphysem der Suiden, etc. Archiv. f. Tierheilkunke, 1906, 
xxxii, H. 425. 

Jolly. Ueber acutes CEdem der Portio vaginalis. Zeitschr. f. Geb. u. Gyn., 1904, 
lii, 396-401. 

Kaltenbach. Diffuse Hyperplasie der Decidua am Ende der Graviditat. Zeitschr. 
f. Geb. u. Gyn., 1878, ii, 225-231. 




LITERATURE 


655 


Kaschewarowa. Ueber die Endometritis decidualis chronica. Vircnow’s Archiv, 
1868, xliv, 103-113. 

Kehrer. Das Nebenhorn des doppelten Uterns. Heidelberg, 1900. 

Keitler. Ein Beitrag znr Retroflexion und Retroversion der schwangeren Gebar- 
mutter. Monatsschr. f. Geb. u. Gyn., 1901, xii, 285-305. 

Lindenthal. Aetiologie der Kolpohyperplasia cystica. Wiener med. Wochenschr., 
1897, Nrs. 1-2. 

Lobenstine. Incarceration of the Pregnant Uterus. Amer. Jour. Obst., 1909, lx, 
1003-1016. 

Maslowsky. See Chapter XXV. 

Mauriceau. Histoire d ’une femme,etc. Traite des maladies des femmes grosses, 
6me ed., 1721, T. I., 86-91. 

Meyer-Ruegg. Eihautberstung ohne Unterbrechung der Schwangerschaft. 
Zeitschr. f. Geb. u. Gyn., 1904, li, 419-468. 

Miller. Clinical Aspects of Uterus Didelphys. Am. Jour. Obst. and Gyn., 1922, 
iv, 378-408. 

Neumann. See Chapter XXV. 

Nyulasy. Polypoid Endometritis. Jour. Obst. and Gyn. British Emp., 1909, 
xvi, 9-15. 

Oldham. Case of Retroflexion of the Gravid Uterus. Trans. London Obst. Soc., 
1860, i, 317-322. 

Reed. The ^Etiology of Ischuria in Retroflexion of the Gravid Uterus. Amer. 
Jour. Obst., 1904, xlix, 145-156. 

Retfferscheid. Beitrag zur Lehre von der Hydrorrhcea uteri gravidi. Zentralbl. 
f. Gyn., 1901, xxv, 1143-1145. 

Sanger. Ueber Schwangerschaft im rudimentaren Nebenhorn bei Uterus duplex. 
Zentralbl. f. Gyn., 1883, vii, 324. 

Sarwey. Carcinom u. Schwangerschaft. Veit’s Handbuch der Gyn., 1899, iii, 
2te Halfte, lste Abth., 489-532. 

Schickele. Die SchAvangerschaft in einem Uterusdivertikel. Beitrage z. Geb. u. 
Gyn., 1904, viii, 267-293. 

Sinclair. A Contribution to the Diagnosis and Treatment of Retro-flexio-versio 
Uteri Gravidi. Trans. London Obst. Soc., 1900, xlii, 338-355. 

Stoeckel. Beitrag zur Lehre von der Hydrorrhoea uteri gravidi. Centralbl. f. 
Gyn., 1899, 1353-1361. 

Van der Hoeven. Hydrorrhcea gravidarum. Monatsschr. f. Geb. u. Gyn., 1899, 
x, 329-337. 

Van der Velde. Geburtsstorungen durch Entwicklungsfehler der Gebarmutter. 
Monatsschr. f. Geb. u. Gyn., 1915, xlii, 307-321. 

Veit. Ueber Endometritis decidua. Volkmann's Sammlung klin. Vortrage, 1885, 
Nr. 254. 

Allgemeines iiber die ^Etiologie der Endometritis in der Graviditat. Zeitschr. 
f. Geb. u. Gyn., 1895, xxxii, 111-116. 

Virchow. Endometritis decidua tuberosa. Die krankhaften Geschwiilste, 1864, 
ii, 478-481. 

Wells. The Clinical Significance of Developmental Duplications of the Uterus and 
Vagina. Amer. Jour. Obst., 1900, xli, 317-365. 

Winckel. Ueber die Cysten der Scheide, etc. Archiv. f. Gyn., 1871, ii, 383-413. 










CHAPTER XXVIII 


DISEASES AND ABNORMALITIES OF THE OVUM 

Any portion of the ovum—chorion, amnion, placenta, or foetus—may 
be the seat of disease, or may present abnormalities. In many instances 
the morbid process is limited to a single portion, while in others a large 
part, or even the ovum as a whole, may be implicated. Accordingly, we 
shall take up successively those lesions or abnormalities which are limited 
to the chorion, amnion, or placenta; next, those in which the entire 
ovum, and finally those in which the foetus alone is affected. 


DISEASES OF THE CHORION 

Hydatidiform Mole .—In this condition, also known as vesicular mole, 
cystic degeneration of the chorion, or myxoma chorii, the terminal ex¬ 
tremities of the chorionic villi are converted into transparent vesicles 
with clear, viscid contents. These vary in size from minute bodies a 
millimeter or less in diameter to cystic structures the size of hazel-nuts, 
and hang in clusters from the villous stems, to which they are connected 
by thin pedicles, giving to the external surface of the chorion a grape¬ 
like appearance. The formation usually involves the entire periphery of 
the membrane, but may be limited to portions of it. 

It is generally stated that the condition was first described by Schenck 
von Grafenberg in 1565, but Kossmann has pointed out that Aetius, of 
Amida, in the early part of the sixth century, wrote intelligently about 
an hydatidiform mole, although he seemed to have no clear idea of its 
nature. 

Owing to its peculiar appearance and the fact that it frequently con¬ 
tained no tract of a foetus, the hydatidiform mole was a source of not a 
little speculation to the early writers upon medicine, and all sorts of 
theories were advanced concerning its origin. As the name implies, the 
condition was long considered to be analogous to the hydatid cysts ob¬ 
served in other parts of the body, Goeze, Percy, and others believing that 
the vesicles contained wormlike structures. Tie Graaf held that the 
vesicles were mature ova, while some authors thought that each repre¬ 
sented an early pregnancy. It is probable that many of the extraordi¬ 
nary cases of multiple gestation recorded in the early literature, such as 
that of Ihe Countess Hagenau, who was believed to have given birth to 
365 embryos at a single labor, were really instances of hydatidiform 
mole. 

The true nature of the affection was first recognized by Velpeau and 

656 



DISEASES OF THE CHORION 


657 


Madame Boivin in 182d, and since then it has been universally admitted 
to be a disease of the chorion. Numerous theories were advanced as to 
the nature of the lesion, until Virchow in 1853 stated that the process 
was essentially a myxomatous degeneration of the connective tissue of 
the chorionic villi, and designated it as myxoma chorii. This view ob¬ 
tained immediate acceptance and held its ground until 1895, when Mar- 
[ chand demonstrated that the essential feature of the affection was to 



Fig. 483. —Uterus Removed by Supravaginal Hysterectomy, Containing a Hyda- 

tidiform Mole. X 1 2. 

be found not so much in the stroma as in the epithelial covering of the 
villi. Fie showed that both the syncytium and Langhans’ layer of cells 
undergo profuse and irregular proliferation, penetrating Nitabuch’s 
fibrin layer and making their way into the depths of the decidua, and 
not infrequently into the uterine musculature as well. At the same 
time the blood vessels of the terminal villi disappear and the stroma 
degenerates, so that in advanced cases its cells become necrotic and their 
nuclei fail to take up the usual histological stains. Moreover, inasmuch 











658 


DISEASES AND ABNORMALITIES OF THE OVUM 


as the fluid contents of the vesicles fail to give the characteristic reaction 
for mucin, Marchand felt justified in attributing them to edema. 

This work obtained almost immediate acceptance, and was promptly 
confirmed by many investigators, among whom Neumann, Fraenkel, 
Pick, Ouvry, Larrier and Brindeau, and Essen-Moller may be men¬ 
tioned. Fig. 484 represents a section through one of my specimens, all 
of which abundantly confirm Marchand’s view. 

With the discovery that the so-called chorio-epithelioma resulted from 
a malignant proliferation of the epithelial elements of the chorion, 
and particularly that it was preceded in from one third to one half of 



,r . 'v .* 

1 *\+ .«> ® f. s i? 

jv-A ■ V. * 


Fig. 484. —Section of Hydatidiform Mole, Showing Proliferation of Syncytium 

and Langhans’ Cells. X 75. 

S., syncytium; V., normal chorionic villi; Z., Langhans’ cells. 


the recorded cases by the expulsion of an hydatidiform mole, great 
interest arose as to the relation which the latter bore to the production of 
the former. The similarity in the microscopic structure of the two 
pathological processes made it apparent that there must be a genetic 
relationship between them, and the question arose whether it existed in 
all cases. 

Neumann, in 1897, held that it was possible to differentiate between 
two forms of hydatidiform mole, one of which was and the other was not 
followed by the development of a chorio-epithelioma. He considered 
that in the former the proliferating epithelium invaded the stroma, 
while in the latter it was limited to the periphery of the villus. His 











DISEASES OF THE CHORION 


659 


observations, however, have not been confirmed, although Pick, Findley, 
Larrier and Brindeau, and many subsequent writers believe that moles 
may occur in one of two forms—benign or malignant—but that the 
differences are biological rather than histological, so that it is impossible 
to predict the outcome of a given case by microscopical examination. 

Marchand, in his original article, stated that in many instances the 
ovaries were likewise the seat of cystic changes. Stoeckel, in 1902, 
showed that one or, more commonly, both ovaries may become converted 
into polycystic tumors, which sometimes attain a diameter of 10 or 15 
centimeters. The individual cysts vary from a few millimeters to 5 or 6 
centimeters in diameter, are filled with clear contents, and are lined by 
one or more layers of lutein cells. Since then it has become generally 
recognized that the lutein cell cystoma is a frequent, but not a universal, 
accompaniment of the condition. 

As lutein cystomata do not occur frequently, their association with 
hydatidiform mole has given rise to a great deal of discussion, certain 
writers holding that they stand in some etiological relation to the mole; 
others that they are secondary to it; while a third group, represented by 
Wallart and Seitz, considers that similar, but less pronounced, changes 
occur in normal pregnancy. While it is generally admitted that the 
theca cell proliferation described by the last mentioned writers is a 
normal concomitant of pregnancy, I do not believe that it is identical 
with the tumor under discussion. Moreover, the fact that only a small 
proportion of hydatidiform moles are associated with lutein cystomata, 
t speaks against the latter being concerned in their etiology, but the 
demonstration by Fraenkel and Santi, and the confirmation by others, 
that lutein cystomata sometimes undergo spontaneous involution within 
a few months after the expulsion of the mole, indicates that there must 
be a genetic relationship between the two processes. In one of my 
patients, whose second pregnancy ended in the expulsion of a large mole, 
both ovaries were converted into polycystic lutein tumors, 15 centimeters 
in diameter. They were successfully removed after laparotomy, and 
constitute my sole experience with this type of tumor. 

Causation .—Positive statements cannot as yet be made concerning 
the etiology of hydatidiform mole. Virchow and Wit held that it was 
dependent upon endometritic changes. At the 1901 meeting of the 
German Gynecological Congress Aichel stated that he had been able 
to produce the condition experimentally in dogs by destroying the vessels 
going to the decidua, but, in view of the fundamental differences in 
structure of the zonal placenta in carnivora and of the discoidal placenta 
in man, the greatest caution should be exercised in making inferential 
deductions. On the other hand, Marchand and most recent writers 
consider the changes in the endometrium as secondary, and seek the 
initial factor in the ovum itself. Durante considers that the condition 
is due to endarteritis of the villous vessels. Plausibility is lent to the 
view that the primary process originates in the ovum by the fact that 
in rare instances of twin pregnancy one ovum may be perfectly normal, 
while the other presents the lesion in question. Mme. Boivin was ac¬ 
quainted with the fact, and cases have been reported by Birnbaum, 





GOO 


DISEASES AND ABNORMALITIES OF THE OVUM 


Falgowski, Lukens, and others. It is hardly probable, if changes in the 
endometrium were the primary cause, that the vesicular change would be 
limited to one ovum. 

Clinical History .—Hydatidiform mole is a rare disease, occurring, ac¬ 
cording to Madame Boivin, once in 20,000 pregnancies. On the other 
hand, the statistics of Williamson, and Sunde would indicate that it may 
be found about once in 2,400 or 3,000 cases; while in my experience it 
occurs even more frequently. It may occur at any period of reproductive 
life, but is particularly frequent in the third and fourth decades, having 
been noted between the twentieth and thirtieth years in 41 and 38 per 
cent, of the cases collected by Borland and Kehrer respectively. Sunde, 
on the other hand, on the basis of 122 personally investigated cases, 
holds that it occurs two and a half times more frequently after the 
fortieth year if the total number of pregnancies is considered. 



Invasion of blood vessel. D. V., dropsical villus; Syn., proliferating syncytium; U. W., 

uterine wall; V., vein. 

The statement of Meyer that the disease was present in over 100 out 
of 348 specimens of abortion, which he examined, should not Be accepted 
without reservation. He referred to degenerative changes in the stroma 
of the villi, which are associated with foetal or embyronic death; while 
in hydatidiform mole one has to deal with an active hyperplasia of the 
chorionic epithelium. Doubtless he is correct, so far as he goes, but he 
was not dealing with true hydatidiform moles. 

The process usually comes on early in pregnancy, rarely making its 
appearance after the third month, and was present in one of my speci-1 
mens 38 days after the last menstrual period. When it develops com- i 
paratively late it does not implicate the entire chorion; but whenever a 
considerable portion of the membrane is involved, atrophic changes 
affecting the foetus are constantly found, and its development is ma¬ 
terially influenced even when the disease is relatively mild in character. 
In the former class of cases the embryo may not be formed at all, or it 











DISEASES OF THE CHORION 


661 


dies at an early period, and undergoes complete dissolution, all trace of 
it disappearing except the maternal end of the umbilical cord. As 
the chorionic villi are nourished by the maternal blood, the mole may 
continue to grow after the death of the embryo, and may attain consider¬ 
able proportions, though spontaneous expulsion is rarely delayed after 
the sixth month. 

The clinical history is very characteristic. The uterus enlarges much 
more rapidly than usual, so that its size does not correspond to the 
supposed duration of pregnancy. This was formerly considered a gen¬ 
eral rule, but the tabulations of Briggs and Essen-Mbller show that in 
many instances the uterus is smaller than would be expected. After a 
longer or shorter period more or less profuse hemorrhage occurs, which 
persists until the mole is cast off spontaneously or removed by the 
physician. 

In a small number of cases, the hypertrophic villi invade the uterine 
wall, following the course of venous channels, and in extreme instances 
the entire muscular is may become disintegrated. This happens in what 
is known as the destructive mole, characteristic examples of which have 
been reported by Krieger, Yolkmann, Jarotsky, and Waldeyer. Now 
and again the growth reaches the peritoneal surface of the uterus and 
gives rise to perforation, followed by fatal intraperitoneal hemorrhage. 
This complication was observed by Wilton, Madame Boivin, Ouvry, and 
others. 

In rare instances, at varying periods after the expulsion of the mole, 
small purplish or reddish tumors may appear in the vagina or about the 
vulva. On microscopic examination, after excision, these are found to 
consist for the most part of blood, through which are scattered dropsical 
villi showing the characteristic epithelial changes. In a number of cases 
recorded, the uterus was normal, and complete excision of the nodule 
was followed by permanent recovery. The question has accordingly 
arisen whether such tumors represent metastases from a chorio-epitheli- 
oma or a malignant hydatidiform mole, or whether they are merely due 
to the accidental transportation of particles of a benign growth. Neu¬ 
mann and Schmidt take the former, while Pick and Schlagenhiiufer 
incline to the latter view. The observations of Veit, Poten, and myself, 
concerning the transportation of villi in normal pregnancy, lend a cer¬ 
tain probability to the latter theory, although the question must be 
settled by future investigations (see Fig. 485). 

Aside from the possibility of the development of a chorio-epitheli- 
oma, which occurred in 16 per cent, of the 210 cases analyzed by Findley, 
but only in 5 per cent, of the cases studied by Sunde, the hydatidiform 
mole is a serious affection, since Borland noted an immediate mortality 
in 10 per cent, of the 100 instances which he collected from the litera¬ 
ture, death being due to hemorrhage at the time of operation in 3 per 
cent., to perforation of the uterus in 2 per cent., and to infection in 5 
per cent, of the cases. Sunde has pointed out that the occurrence of 
hydatidiform mole has no effect upon subsequent fertility, although 
Essen-Moller has shown that it may recur in successive pregnancies, and 
has collected 18 illustrative cases from the literature. 




662 


DISEASES AND ABNORMALITIES OF THE OVUM 


As was indicated in the chapter upon the toxemias of pregnancy, 
the growth may in rare instances be associated with pre-eclamptic tox¬ 
emia, and Fig. 483 represents a mole within a uterus which had been 
removed because of this complication. 

Diagnosis .—Hydatidiform mole should always be suspected when 
hemorrhage occurs in a patient over thirty years of age whose uterus is 
considerably larger than it should be for the supposed duration of preg¬ 
nancy, though in not a few cases similar symptoms are noted in hydram- 
nios. A positive diagnosis may be made when one finds one or more 
vesicles in the uterine discharges, or when the finger introduced through 
the cervical canal is able to palpate the characteristic grapelike masses. 

Treatment .—Owing to its inherent danger, but especially to the pos¬ 
sible subsequent development of a chorio-epithelioma, the uterus should 
be emptied as soon as a positive diagnosis is made. Bv means of a gauze 
pack or a steel dilator, the cervix should be dilated sufficiently to admit 
two fingers, with which the growth is peeled off from the uterine wall 
and then removed. Care should be taken that the manipulations are 
made as gently as possible in order to avoid a possible perforation of the 
uterus, whose walls are likely to have been weakened by the invasion of 
the growth. After removal of the mole, the uterine cavity should once 
more be explored to make sure that it is thoroughly empty. 

In view of the danger inherent to this abnormality, Schumann has 
advised opening the uterus by abdominal hysterotomy, and removing it, 
or sewing it up after the removal of its contents, according to the con¬ 
ditions found. I consider his recommendation unduly radical, and feel 
sure that it will lead to the unnecessary sacrifice of many uteri. At the 
same time, I should not disapprove of routine hysterectomy whenever the 
condition develops in women at'the end of the period of sexual activity. 

Every woman who has expelled a hydatidiform mole should be care¬ 
fully watched for the next year, and if hemorrhage makes its appearance 
the uterus should be curetted and the scrapings subjected to microscopic 
examination; and, if the lesions characteristic of chorio-epithelioma are 
found to be present, immediate hysterectomy is imperative, in the hope 
of avoiding metastases. On the other hand, as has already been pointed 
out, vaginal or vulval metastases may occur without any apparent in¬ 
volvement of the uterus. Under such circumstances, the metastases 
should be excised, but the uterus left in place, as the history of similar 
cases shows that the majority of the patients recover permanently. 

Chorio-epithelioma.—This term is applied to a very malignant variety 
of tumor which develops after full-term labor, abortion, or hydatidiform 
mole, and in rare instances even before the last is expelled from the 
uterus. The nature of the growth has given rise to a great deal of dis¬ 
cussion, and various appellations have been suggested for it, the most 
important being decidnoma malignum, sarcoma deciduocellulare, syn- 
cytioma malignum, and carcinoma syncytiale. 


The first case was described in 1892 by Sanger, who based his article 
upon the following case: A woman, twenty-three years of age, aborted 
in the eighth week and died seven months later. At autopsy four large, 
soft, reddish, spongy tumors were found in the uterine wall, with 








DISEASES OF THE CHORION 


663 


metastases exhibiting similar characteristics in the lungs, diaphragm, 
tenth rib, and right iliac fossa. Microscopic examination showed that the 
tumor was made up in great part of blood spaces bounded by large cells, 
which were considered decidual in origin. The metastases presented a 
similar appearance and had resulted from the transportation of tumor 
masses through the venous channels. As Sanger believed that the tumor 
was derived from decidual cells and was therefore of connective-tissue 
origin, he designated it decidual sarcoma or sarcoma uteri deciduocellu- 
lare. The appearance of his monograph in 1893, in which was collected 
all that was then known upon the subject, created profound interest, and 
was soon followed by the publication of many similar cases. 

In 1895 I published a monograph upon the subject, in which I 
reported a case and collected 24 others from the literature. My patient 




- - x • . .• ..., 


s? A „ 

i -... I- # 

/. • V ,-y i ■ 







•<£_ 


Fig. 486. —Chorio-epithelioma, showing Alveolar Arrangement of Primary Tumor. 

X 60 . 


was a colored woman, who, one week after a spontaneous full-term 
labor, noticed a small painful nodule upon the right labium majus. This 
resembled a hematoma in appearance, rapidly increased in size, and 
within two weeks became as large as a hen’s egg. Shortly afterward it 
underwent necrotic changes, which were accompanied by a profuse, foul¬ 
smelling discharge. The patient gradually grew worse, eventually de¬ 
veloped a cough and bloody expectoration, and died six months after 
delivery. The nature of the vulval tumor was not suspected during life, 
but at autopsy the lungs were found to be studded with large numbers 
of metastases of varying size, which resembled placental tissue in appear¬ 
ance. Similar growths were present in the kidneys, spleen, and ovary, 
while the primary uterine tumor was a small nodule about 1 centimeter 
in diameter. 

Microscpic examination showed that the uterine growth and the 
metastases were made up in great part of blood spaces, whose walls were 





664 


DISEASES AND ABNORMALITIES OF THE OVUM 


formed by large clear cells with definite vesicular nuclei. At the margins 
of the primary growth, invading the adjacent musculature, were large 
masses of syncytium; the nature of the individual cells was not so 
clear, although I was inclined to consider them due to transverse and 
oblique sections through the syncytial strands. 

The same year Marchand wrote an important monograph upon the 
subject. He identified the protoplasmic masses with the syncytium, and 
the individual cells with those of Langhans’ layer. At that time it 
was generally believed that the former was of maternal and the latter of 
foetal origin; accordingly he held that the tumor was epithelial in origin, 
and was composed partly of maternal and partly of foetal tissue. Hence 
it followed that such tumors could not correctly be described as deciduo- 
mata or decidual sarcomata. Three years later, after it had been demon- 
strated that both layers of the chorionic epithelium were foetal in origin, 
he proposed the term cliorio-epithelioma, which has since been generally 
accepted. 

The monographs of Sanger and Marchand were the beginning of an 
extensive literature upon the subject, which has rapidly increased in 
volume. Thus, Teacher, and Briquel in 1903 were able to collect 188 and 
254 cases respectively, and Frank in 1906 analyzed 28 cases which had 
been reported in America; while Vineberg was able to collect 533 cases, 
which had been described in the literature up to 1917. 

Risel, working in MarchamFs laboratory, contends that chorio-epithe- 
lioma may occur in a typical and an atypical form. In the former the 
tumor cells present an appearance identical with that presented by the 
chorionic epithelium in early pregnancy, while in the latter the foetal 
cells merelv infiltrate the uterine wall, without necessarily giving rise 
to a true tumor formation. Both varieties are equally malignant and 
give rise to metastases. 

In other instances, the primary growth may originate outside of the 
uterus. Thus, Risel in 1914 was able to collect 22 cases in which it had 
originated in the tube, and Sunde and I have observed additional in¬ 
stances; while Fairbairn, Klotz, Risel, Seitz, and others have reported 
cases in which it developed in the ovary. In the latter instance one’s 
first tendency would be to associate the condition with an ovarian 
pregnancy or with a teratoma, but, while such an origin cannot be de¬ 
nied, Risel believes that in most cases the ovarian tumor is derived from 
a primary uterine growth, which had long since disappeared. In still 
other cases, as reported by Schmorl, IHibl, Findley, and others, there was 
no trace of a primary growth in the uterus, tubes, or ovaries, but the 
patient nevertheless died from metastases in various organs. At first 
it was attempted to explain such an occurrence by assuming that the 
primary growth had been limited to the placenta, particles of which 
became broken off and were carried into the circulation, giving rise to 
metastases, while the primary tumor itself was cast off with the after¬ 
birth. Later, however, as the frequency of the “deportation” of chorionic 
villi became more fully recognized, it was assumed that, metastases might 
develop in any case in which the chorionic epithelium possesses malig¬ 
nant, properties. Poten and Yassmer have reported a case in which 









DISEASES OF THE CHORION 


665 


vaginal metastases appeared while an hydatiform mole was still present 
in the uterus. 

The chorio-epithelioma rapidly gives rise to abundant metastases, 
particularly in the lungs, vagina, and brain. They develop along the 
course of venous channels, which is explained by the tendency of the 
foetal ectodermal cells to arrode, and eventually invade, the blood vessels 
with which they come in contact. In the 52 cases collected by Borland, 
metastases were observed in the lungs of 78.38 per cent., in the vagina 
of 54 per cent., and in the kidney, spleen, and ovary of 13.5 per cent., 
of the liver, broad ligament, and pelvis respectively 10.8 per cent., and 
in the brain 5.4 per cent. The vaginal metastases are of particular sig- 



H.BericerJec. 

Fig. 4S7. —Chorio-epitheolioma, showing Syncytial Masses invading a \ enous 

Channel. 


nificance, and occasionally are the only manifestation of the condition. 
In some cases, as reported by Hermann and others, their excision may 
be followed by complete recovery. 

Runge in 1903 pointed out that lutein cystomata were sometimes ob¬ 
served in the ovaries. Upon analyzing 63 cases of chorio-epithelioma in 
which the condition of the ovaries was described, he found such forma¬ 
tions in 24 instances; but, just as is the case in hydatidifoim mole, 
neither he nor subsequent investigators have been able to adduce a satis¬ 
factory explanation of their significance. 

In 1902 Wlassow and Schlagenhaufer made a contribution, which 
for a time threatened to overturn our ideas concerning the significance 
and mode of origin of chorio-epitheliomata. They described generalized 



666 


DISEASES AND ABNORMALITIES OF THE OVUM 


metastases following certain teratomata of the testicle, which were made 
up of syncytium, Langhans* cells, and even of structures resembling 
chorionic villi. Their observations have been abundantly confirmed by 
Risel, Teacher, Frank, and others; while Pick and others have reported 
similar conditions associated with ovarian ^ teratomata. 

In such cases, Schlangenhaufer assumed that portions of foetal mem¬ 
branes had been included in the teratoma, and suddenly began to 
proliferate after lying dormant for years. Risel and all subsequent 
writers, on the other hand, hold that such an assumption is unnecessary, 
as they consider that the tumor may develop from undifferentiated foetal 
ectoderm contained in the teratoma. 

Clinical History. —Chorio-epithelioma may occur at any age during 
the childbearing period, but according to Sunde it is relatively most fre¬ 
quent after the fortieth year. Except in the rare cases associated with 
teratomata, it always follows a pregnancy, no matter whether the latter 
is situated in the uterus, tube or ovarv, or terminates in full-term labor, 
abortion, or hydatidiform mole, the last association being noted in nearly 
50 per cent, of the cases. The converse, however, does not hold good, as 
only 5 per cent, of the 122 moles studied by Sunde were followed by the 
tumor. 

Ordinarily there is no suspicion of the existence of the growth during 
pregnancy, or even during the first few weeks after delivery. In a 
small number of cases hemorrhage in the latter part of the puerperium i 
may be the first indication of its existence, though this symptom is 
usually lacking. Occasionally a much longer period may elapse, and 
Krosing has collected 16 instances in which a period of latency, varying 
between 1 and 9 years, was noted; while Sunde observed it in 5 of his 
34 cases. Ries has given a satisfactory explanation for such an ap¬ 
parently contradictory development, as he was able to demonstrate the 
presence of chorionic villi in the uterus of an elderly woman 18 years 
after the termination of her last pregnancy. In more than one half 
of the cases the first indication is the appearance of vaginal or vulval 
metastases some weeks or months after the puerperium, though in Poten 
and YassmePs case they appeared before the extrusion of the mole. The 
development of metastases in the lungs is usually associated with' pul¬ 
monary symptoms, cough, and bloody expectoration. Occasionally, as 
reported by Hermann and others, the growth may perforate the uterine 
wall and give rise to fatal intraperitoneal hemorrhage. Unless removed 
by operative procedures, the tumor rapidly causes death, the majority of 
patients succumbing within the first year. Indeed, it may be said that, 
in general, this is the most rapidly fatal malignant growth with which 
we are acquainted, though occasionally cases are encountered in which 
permanent cure follows a simple curettage. 

Diagnosis .—If the existence of the growth is not indicated by the 
early occurrence of vaginal or vulval metastases, the diagnosis is not 
made until uterine hemorrhage, occurring at a varying period after the 
puerperium, necessitates curettage, when the microscopic examination 
of the scrapings reveals characteristic changes. 

The possibility of its development should be especially borne in mind 





DISEASES OF THE AMNION 


667 


whenever a woman has expelled a hydatidiform mole, in whom the sub¬ 
sequent appearance of hemorrhage, or of other more obscure symptoms, 
should be an imperative indication for curettage and the microscopic 
examination of the scrapings. 

Treatment. —If curettage reveals the existence of characteristic 
lesions in the uterus, immediate abdominal hysterectomy is imperative. 
On the other hand, when only vaginal metastases are present, the indi¬ 
cations for radical operation are not so clear, as we know that the 
excision of the vaginal tumors may be followed by complete recovery. 
If, however, the uterus is also involved, hvsterectomv as well as excision 
of the metastases is indicated, though the chances for ultimate recovery 
are very slight. In such cases properly supervised radium treatment may 
be valuable. 

Diffuse Myxoma of the Chorion.—Breslau and Eberth have called 
attention to a rare affection of the chorionic membrane, in which its 
connective tissue layer undergoes myxomatous degeneration and becomes 
converted into a jellylike substance analogous to the whartonian jelly 
of the cord. This layer may attain a thickness of 4 to 5 millimeters, but 
does not appear to exert any special influence upon pregnancy. 


DISEASES OF THE AMNION 

Hydramnios.—By hydramnios is understood the presence of an exces¬ 
sive quantity of liquor amnii. Exactly when the proper limit is passed 
cannot be stated with accuracy, for the reason that the authorities do not 
agree as to the amount to be considered normal, Fehling placing it at 
680 and Gassner at 1,877 cubic centimeters, though, generally speaking, 
a quantity greater than 2 liters may certainly be considered excessive. 

Minor degrees of hydramnios —2 to 3 liters—are common, but the 
more marked grades are not frequent. In rare cases the uterus may 
contain an almost incredible amount of liquor amnii, Kiistner having 
observed 15 liters, and Schneider 30 liters at the fifth and sixth months 
of pregnancy respectively. In most cases the increase in the amount of 
amniotic fluid is quite gradual, but exceptionally it takes place very 
suddenly, so that the uterus may become immensely distended within a 
few days —acute hydramnios. 

The fluid in hydramnios is usually identical in appearance and 
composition with that normally present in the amniotic cavity, although 
Prochownick states that the former occasionally contains a slightly 
increased amount of urea. 

Etiology .—As was said when the physiology of the foetus was dealt 
with, the amniotic fluid is normally derived from the fluids of the 
mother, which have been modified by the secretory action of the amniotic 
epithelium; while the foetal kidneys take no part in its production, ex¬ 
cept under abnormal conditions. This being the case, it is manifestly 
impossible to give an explanation for its excessive production which will 
be universally applicable. 

Generally speaking, writers upon the subject state that the excess of 






668 


DISEASES AND ABNORMALITIES OF THE OVUM 


amniotic fluid may be derived from several sources—from the foetus, 

*/ 

from the mother, from both foetus and mother, and in rare cases from 
the amnion itself. 

In a certain proportion of cases careful examination of the foetus 
after death reveals the presence of some abnormality which may possibly 
bear a causal relation to the disease. Thus, hydramnios is sometimes, 
though not always, noted when the foetus presents some abnormality or 
deformity, particularly hemicephalus or spina bifida. Under such cir¬ 
cumstances, it is believed that the superabundant fluid results from ex¬ 
cessive urinary secretion, which is brought about by the stimulation of 
cerebral or spinal centers which have been deprived of their usual cover¬ 
ings, just as happens in the piqure experiments of the physiologists. 
Hydramnios is also found associated with other deformities, such as 
harelip, the various varieties of club-foot, ectopia of the bladder, etc., 
as well as certain tumors of the kidneys. 

More frequently, however, the abnormality which is supposed to give 
rise to hydramnios is to be found in lesions which cause obstruction to 
the circulation either in the cord or within the foetus. In other in¬ 
stances the condition is attributed to renal changes or to abnormalities 
in the cutaneous functions. 

Sallinger has shown that an obstruction to the circulation in the um¬ 
bilical vain is accompanied by an exudation of fluid from the external 
surface of the umbilical cord and from the foetal surface of the placenta. 
This he attributed to the persistence of the so-called vasa propria of 
Jungbluth, which, springing from the foetal end of the cord, lie between 
the chorion and amnion and usually become obliterated in the second 
half of pregnancy. Analogous observations have been made by Levison. 
According to Franque, obliterative changes in coats of the arteries of the 
chorionic villi may lead to similar results. Leopold and Bar have shown 
that the obstruction may be due to stenosis or thrombosis of the umbilical 
vein, while Fehling has attributed it to torsion of the cord. 

More frequently the obstruction lies within the foetus. Thus Opitz 
observed cirrhotic changes in the liver in all of his cases. Others have 
attributed it to syphilitic changes, though in my experience lues is an 
unimportant factor, as hydramnios does not occur more frequently .in 
syphilitic than in normal children. In a small number of cases the 
obstruction to circulation is due to cardiac abnormalities. Thus, Woerz 
found the right auricle almost entirely occluded by a rhabdomyoma. 
Bar observed tricuspid insufficiency and stenotic changes about the pul¬ 
monary arteries; Lebedeff, aortic stenosis, and Nieberding, a narrowing 
of the ductus Botalli. 

Many authorities believe that in a certain number of cases hydram¬ 
nios is due to an excessive urinary secretion resulting from renal or 
cardiac lesions on the part of the foetus. Opitz thought he had demon¬ 
strated that in hydramnios the liquor amnii contained a lvmphagogue 
substance, which is normally absent. He considered that its presence in 
the tissues of the foetus resulted in the extraction from the intervillous 
spaces of the placenta of a greater amount of fluid than usual. This 
necessitated increased exertion on the part of the heart, which eventually 


DISEASES OF THE AMNION 


669 


resulted in its hypertrophy. As a consequence a larger amount of fluid 
circulated through the kidneys, giving rise to an increased urinary secre¬ 
tion. 

It is generally believed that the etiological importance of increased 
renal activity is strikingly illustrated in hydramnios occurring in single¬ 
ovum twins. Wilson (1899) analyzed the histories of 51 cases of 
hydramnios occurring in multiple pregnancy—46 twins and 4 triplets. 
Twenty-two of the twins were uniovular in origin, and, when one con¬ 
siders that these are four times less frequent than double-ovum twins, it 
is apparent that something connected with the former must exert an 
appreciable influence in the excessive production of amniotic fluid. In 
such cases, as a rule, the twins differ materially in size, and the hydram¬ 
nios is limited to the amnion enclosing the larger one, while the other 
contains a normal or diminished amount of fluid. At autopsy the heart 
and kidneys of the foetus accompanied by hydramnios are found to be 
both relatively and actually larger than those of the smaller twin. 
Wilson attributed this difference to the presence in the single placenta 
of an area of circulation common to both twins, and believed that one, 
for some reason, received a larger amount of blood than the other, this 
excess giving rise to cardiac hypertrophy which still further accentuated 
the condition, and in turn was followed by renal hypertrophy with in¬ 
creased secretion. He considered that the primary cause for the differ¬ 
ence in the amount of fluid received by the two twins was to be found 
in abnormalities of the umbilical cord, by which the flow of blood to one 
child was rendered more difficult, as in the cases which he analvzed the 
affected twin always presented some abnormality of that structure— 
velamentous insertion, excessive length, or marked narrowing. 

The mode of production of hydramnios in such cases has been con¬ 
sidered in detail by Schatz, Werth, Straussmann, and Kiistner. The last- 
named authority believes that the cardiac hypertrophy comes about in the 
manner alreadv mentioned, and leads to a still further increase in the 
amount of circulating fluid. Eventually the heart becomes unequal to its 
task and insufficiency results, which is followed by signs of obstruction, 
particularly in the liver, thereby completing a vicious circle. Scheib, 
on the other hand, considers that the fluid is a transudate through the 
umbilical vein, which is brought about by the congestion consequent 
upon failure of compensation. 

Some authors consider that the skin plays a not unimportant part in 
the excessive formation of liquor amnii. Budin in one case was inclined 
to attribute it to a large nevus, through which he believed excessive 
exudation occurred. Furthermore, Wilson and others consider that 
excessive cutaneous activity is ofttimes associated with cardiac hyper¬ 
trophy. 

In a small number of cases inflammatory conditions of the amnion 
itself are believed to play a part in the production of the condition, 
leading to increased exudation through that membrane. 

Occasionally diseases of the mother which are attended by circulatory 
disturbances, particularly cardiac and renal affections, or visceral syph¬ 
ilis, lead to edema of the placenta, with increased transudation into the 







670 


DISEASES AND ABNORMALITIES OF THE OVUM 


amniotic cavity. The demonstration by Wolff that nephrectomy in preg¬ 
nant rabbits was followed by increased renal activity on the part of the 
foetus, with consequent hydramnios, also indicates the possibility of a 
similar occurrence in pregnant women suffering from serious renal dis¬ 
ease. One or other of the conditions just mentioned may account for the 
excessive production of amniotic fluid in a considerable proportion of 
the cases; but at the same time they do not always afford a satisfactory 
explanation, inasmuch as in many instances careful search fails to reveal 
the presence of any condition which can be supposed to play a part in 
its production. 

Symptoms .—The symptoms accompanying hydramnios arise from 
purely mechanical causes, and are due to the pressure exerted by the 
over-distended uterus upon adjacent organs. The effects are particularly 
marked in the respiratory functions, and, when the distention is ex¬ 
cessive, the patient may suffer from severe dyspnea and cyanosis, and 
in extreme cases be able to breathe only in an upright position. Edema 
often occurs, especially in the lower extremities and about the vulva. 

It is surpising what great degrees of abdominal distention can some¬ 
times be borne by the patient with comparatively little discomfort, al¬ 
though this is the case only when the accumulation of fluid has taken 
place gradually. On the other hand, in acute, hydramnios, a much 
slighter degree of distention may lead to disturbances sufficiently serious 
to threaten the life of the patient. 

Diagnosis .—In moderate degrees of hydramnios palpation and per¬ 
cussion enable one to feel confident that the fluctuant tumor is the dis¬ 
tended uterus, in which a readily ballottable foetus can be felt, although 
its heart sounds are heard with difficulty. 

The excessive enlargement of the abdomen due to multiple pregnancy 
occasionally renders the differentiation from hydramnios almost impos¬ 
sible; particularly, as the latter is a frequent complication of the former 
condition. In such cases the hydramnios is usually detected, whereas the 
multiple pregnancy associated with it may pass unnoticed. On the 
other hand, in a multiple pregnancy not complicated by hydramnios, 
the diagnosis is comparatively easy, inasmuch as the large uterus is not 
fluctuant, while careful palpation will reveal the presence of several foetal 
poles and an unusual number of small parts. 

'When the uterine distention is so excessive that the foetus cannot be 
felt, the diagnosis of hydramnios becomes even more difficult, and many 
cases are recorded in which the condition was mistaken for a large 
ovarian cystoma, with the result that an unnecessary laparotomy was 
performed. Inquiry as to the possibility of pregnancy and careful ex¬ 
amination will generally serve to prevent such an error. 

Excessive abdominal enlargement due to ascites can usually be differ¬ 
entiated by the characteristic changes in percussion. In rare instances 
pregnancy, complicated bv a large ovarian cystoma, may be mistaken for 
hydramnios. In some cases the detection of two tumors—one corre¬ 
sponding to the uterus and the other to the cyst—will permit a correct 
diagnosis, but in others the condition may escape detection until after 
childbirth. 


DISEASES OF THE AMNION 


671 


Treatment. Minor grades of hydramnios rarely require active treat¬ 
ment. On the other hand, when the abdomen is immensely distended 
and respiration is seriously hampered, the termination of pregnancy is 
uigently indicated no matter to what period it may have advanced. In 
such cases interference is the more justifiable, since experience teaches 
that premature labor frequently occurs spontaneously if the patient is 
left alone, and that the child is often so poorly developed or so deformed 
that its chances of living are minimal. 



When necessary, the symptoms can be promptly relieved by per- 
foiating the membranes through the cervix, and labor pains set in after 
the amniotic fluid has drained off. In many instances the course of labor 
is greatly prolonged as a result 
of the loss of tonicity of the 
uterine musculature incident to 
excessive distention. In other 
cases it may be almost pre¬ 
cipitate, and in this event there 
is an increased risk of atonic 
hemorrhage during and just 
after the completion of the 
third stage. For this reason 
the uterus should be carefully 
watched, and appropriate 
treatment instituted at the 
slightest sign of danger. 

Oligohydramnios.—In rare 
instances the amount of amni¬ 
otic fluid may fall far below 
«/ 

the normal limits, and occa¬ 
sionally be represented by 
only a few cubic centimeters of clear, viscid fluid. 

The etiology is even less well understood than that of hydramnios. 
Jaggard, in 1894, reported a case in which the foetus presented an 
imperforate urethra with absence of one and cystic degeneration of the 
other kidney, and he therefore concluded that the lack of amniotic fluid 
was the result of non-secretion of urine. lie likewise collected several 
instances from the literature, in which the anomaly was associated with 
complete absence of both kidneys. 

When oligohydramnios occurs early in pregnancy it is attended by 
serious consequences to the foetus, as adhesions may be formed between 
its external surface and the amnion and give rise to serious deformities. 
When occurring later, its effect upon the foetus, though less marked, is 
quite characteristic. Under such circumstances the latter is subjected to 
pressure from all sides and takes on a peculiar appearance, and many 
minor deformities, such as club-foot, are frequently observed (Fig. 488). 

In some cases of oligohydramnios the skin of the foetus is markedly 
thickened, and presents a dry, leathery appearance. Most authorities at¬ 
tribute this to the lack of amniotic fluid, but Ahlfield is inclined to 
believe that it is the cause and not the result of the condition, since the 


Fig. 488. —Compression of Fcetus in 
Oligohydramnios (Ahlfeld). 


V 





672 


DISEASES AND ABNORMALITIES OF THE OVUM 




skin lesion may be so marked as to interfere with the normal cutaneous 
functions and thus do away with one of the sources of the liquor amnii. 

Amniotic Adhesions.—In oligohydramnios, and occasionally even 

when the liquor amnii is present in 
normal amounts, adhesions may form 
between the amnion and the surface of 
the foetus. According to Simonart, 
Chaussier in 1812 was the first to direct 
attention to this condition, and its 
consequences were further studied by 
Montgomery, G. Braun, Kiistner, Ahl- 
feld, Chiari, and others. 

The effects of amniotic adhesions 
are variable and depend in great meas¬ 
ure upon their location. As a rule, 
when they develop early in pregnancy 
they give rise to serious deformities of 
the foetus. The following abnormalities 
have been directly traced to the con¬ 
dition : Encephalocele or hemicephalus; 
fissure of the face, jaw, or lips; fissure 
of the thorax with ectopia cordis, and 
eventration with hernia of the umbilical 
cord. 

In other instances, amniotic bands 
may encircle an extremity of the 
foetus and so compress it as to lead to strangulation and subsequent 
spontaneous amputation. Fig. 490 represents intra-uterine amputation 
of the fingers, and Fig. 491 amputation of the arms, produced in this 
way. Braun has reported two cases 
in which the death of the foetus 


Fig. 489. — Encephalocele re¬ 
sulting from Amniotic Ad¬ 
hesions (Ahlfeld). 



Fig. 490. —Amputation of Fingers by 
Amniotic Adhesions (Kustner). 


Fig. 491. —Amputation of Arm by Amni¬ 
otic Adhesions. 


was attributable to strangulation of the umbilical cord by such bands. 
Exceptionally amniotic adhesions may give rise to dystocia, and Bar- 
deleben and myself have seen instances in which firm adhesions extend- 















ABNORMALITIES OF THE PLACENTA 


673 


ing from the placenta to the child seriously interfered with its birth. 

Inflammation of the Amnion.—Occasionally inflammatory processes 
implicate the amnion. These are usually associated with similar changes 
in the chorion and decidua, and result from preexisting gonorrhoea, from 
attempts at criminal abortion or from the extension of an intrapartum 
infection. 

Cysts of the Amnion.—Now and again small cystic structures, lined 
by typical epithelium, may be formed in the amnion. They generally 
result from the fusion of amniotic folds with subsequent retention of 
fluid. Special attention has been devoted to this subject by Ahlfeld. 
The same observer lias also described a dermoid cvst of the amnion, 
which does not, however, bear critical examination, inasmuch as the 
small particles found in it were probably mere concretions. 

Amniotic Caruncles.—Under this name have been described certain 
nodules which occur upon the foetal surface of the placenta, as well as 
upon the free amnion. Usually they appear in the neighborhood of the 
insertion of the cord as multiple, rounded or oval, opaque elevations, 
which vary from less than 1 to 5 or 6 millimeters in diameter. 

Under the microscope they are seen to be made up of typical stratified 
epithelium. The lowest layer is cuboidal in shape and is continuous 
with the amniotic epithelium, while the upper layers become more and 
more flattened, and stain less and less well as the surface is approached. 
Such structures were found by my assistant, Solon B. Dodds, in 60 per 
cent, of a large series of placentae. As yet we are ignorant of their 
significance, although in the ruminants, in which they are very abundant 
and attain considerable proportions, they contain large quantities of 
glycogen. 

ABNORMALITIES OF THE PLACENTA 



Abnormalities in Size, Shape, and Weight.—The normal placenta is 
a flattened, roundish, or discoid organ, which averages from 15 to 20 
centimeters in diameter, and 
from 1.5 to 3 centimeters in 
thickness. As compared with 
the foetus, it is relatively larger 
in the earlier than in the later 
months of pregnancy, and 
varies considerably in size at 
term, though, generally speak¬ 
ing, the thickness is in inverse 
proportion to its area. Now 
and again, when inserted in the 
neighborhood of the internal 
os, the placenta may take on 
a horseshoelike appearance, its Fig. 492 — Placenta Fenestrata (Hyrtl). 
two branches running partially 

around the orifice. In very rare instances, as reported by Taurin, it 
may be a broad annular organ which encircles the uterine cavity just 
as the zonal placenta in carnivorous animals. 



674 


DISEASES AND ABNORMALITIES OF THE OVUM 




The normal full-term placenta on an average weighs about one sixth 
as much as the child— i. e., somewhere in the neighborhood of 500 grams. 
Exceptionally it may be considerably heavier, Levy having reported a 
number of cases in which it exceeded 1,000 grams in weight. In dis¬ 
eased conditions, on the other hand, this proportion no longei holds 
good, and in syphilis the placenta may weigh one fourth, one third, or 

even one half as much 

as the foetus. In albu¬ 
minuria similar ratios 
obtain, which are due 
almost entirely to the im¬ 
perfect development of 
the foetus which charac¬ 
terizes such conditions. 
The largest placentae 
with which we are famil¬ 
iar are observed in cases 
of general dropsy of the 
foetus and placenta. In 
one of my cases of this 
Fig. 493.—Placenta Bipartita. character the foetus and 

placenta weighted 1,140 
and 1,200 grams, respectively, and in another the placenta weighed over 
2,000 grams. Cohen has reported a case in which the placenta weighed 
2,900 grams. 

Multiple Placenta in Single Pregnancies.—Occasionally in a single 
pregnancy the placenta is divided into several parts, which may be abso¬ 
lutely distinct, or more or less closely united. Such abnormalities have 
been studied 
more particu¬ 
larly by Hyrtl 
and Ribemont - 
Dessaignes, the 
latter stating 
that they occur 
about once in 
352 cases. 

In rare in¬ 
stances the pla¬ 
centa may be ob¬ 
long in shape, 

with an aperture Fig. 494 ._p LACENTA Tripartita (Hyrtl). 

of varying size 

somewhere in the neighborhood of its center. To this abnormality Hyrtl 
applied the term placenta fenestrata. More frecpiently, the organ is 
more or less completely divided into two lobes. When the division is 
incomplete, and the vessels extend from one lobe to the other before 
uniting to form the umbilical cord, we speak of a placenta dimidiata or 
bipartita (see Fig. 493). According to Ahlfeid, this anomaly is noted 




ABNORMALITIES OF THE PLACENTA 


675 




about once in 600 cases. xAgain, the two lobes may be quite separate, 
the vessels being perfectly distinct and not uniting until just before 
entering the cord placenta duplex. Occasionally the organ may be 
made up of three distinct 
lobes— placenta triplex; 
while in very rare in¬ 
stances it may consist of 
a number of small lobes, 

Hvrtl having described 
as many as seven— pla¬ 
centa septuplex. 

All of these condi¬ 
tions result from ab¬ 
normalities in the blood 
supply of the decidua. 

Generally speaking, the 
portion of the ovum 
which is to become con¬ 
verted into the chorion 
frondosum, and later into the foetal portion of the placenta, is that 
which is in contact with the most highly vascularized portion of the 
decidua. If the vascularization, instead of being practically limited to 

a single area, de¬ 
velops in several 
separate portions 
of the decidua, 
some such anom¬ 
aly is bound to 
occur. Kiistner 
believes that cer¬ 
tain cases of pla¬ 
centa bipartita 
or duplex owe 
their origin to 
extensive infarct 
formation by 
which the inter¬ 
vening tissue is 
destroyed ; b u t 
such an explana¬ 
tion cannot be 
accepted when 
the several 
lobules are sepa¬ 
rated from one another by apparently normal membranes. 

Placenta Succenturiata.—An important, and not infrequent, anomaly 
is the so-called placenta succenturiata, in which one or more small ac¬ 
cessory lobules are developed in the membranes at some distance from 
the periphery of the main placenta. Ordinarily they are united to the 


Fig. 496.—Placenta Duplex, with Two Succenturiate 

Lobules. X 








Fig. 495.—Corrosion Preparation of Placenta 
Septuplex (Hyrtl). 










676 


DISEASES AND ABNORMALITIES OF THE OVUM 




Fig. 497. —Placenta Membranacea 
(von Weiss). 


latter by vascular connections. Occasionally, however, these are lacking, 
and as a result we have what are known as 'placentae spuriae. 

The placenta succen- 
turiata is of considerable 
clinical importance, because 
the accessory lobules are 
sometimes retained in the 
uterus after the expulsion 
of the main placenta, and 
may give rise to serious 
hemorrhage. For this 
reason, one should always 
bear in mind the possibility 
of their existence, and, in 
examining the after-birth, 
the membranes should be in¬ 
spected, as well as the pla¬ 
centa. Should small, round¬ 
ish defects be present a 
short distance from the pla¬ 
cental margin, the retention 
of a succenturiate lobe 
should be suspected, and this 
becomes a certainty if ves¬ 
sels extend from the pla¬ 
centa to the margins of the tear. If, in such cases, even slight hemor¬ 
rhage occurs, the hand should be introduced into the uterus for the pur¬ 
pose of locating 
and removing 
the offending 
structure. 

Placenta 
Membranacea. — 

In rare instances 
the decidua re- 
* flexa is so abund- 
a n 11 y supplied 
with blood that 
the chorion laeve 
in contact with 
it fails to under¬ 
go atrophy. In 
such circu in¬ 
stances, the en¬ 
tire periphery of 
the ovum is cov¬ 
ered by function¬ 
ing villi, so that the placenta, instead of being a discoidal*organ limited 
to the decidua serotina, is a thin membranous structure occupying the 


Fig. 498. —Placenta Marginata. X 





DISEASES OF THE PLACENTA 


G77 


entire periphery of the chorion— placenta membranacea. This abnormal¬ 
ity does not interfere with the nutrition of the ovum, but occasionally 
gives rise to serious complications during the third stage of labor, since 
the thinned-out placenta does not readily separate from its area of 
attachment and causes profuse hemorrhage. This necessitates manual 
removal, which is sometimes very difficult. 

Placenta Marginata.— Placenta marginata will be considered later 
in the chapter when we come to speak of infarcts of the placenta. 

Placenta Circumvallata. —In exceptional instances, the foetal surface 
of the placenta may present a central depression surrounded by an ele¬ 
vated portion, the amnion extending from the edges of the former. This 
condition is designated as placenta circumvallata, and is due to a 
proliferation of the villi at the margin of the placenta after the definite 
attachment of the amnion has occurred. 

Placenta Previa. —Once in several hundred cases the placenta, instead 
of being inserted upon the anterior or posterior wall or the fundus of the 
uterus, is implanted upon the lower uterine segment in such a manner 
as more or less completely to overlap the internal os— placenta previa. 
As this condition is unavoidably associated with hemorrhage during the 
first stage of labor, and is a most serious complication, it will be dealt 
with in a separate chapter. 


DISEASES OF THE PLACENTA 

Infarct Formation. —The most frequent abnormality of the placenta 
consists in the development of certain degenerative changes, which have 
been variously designated as placentitis, schirrus, atrophy, hepatization, 
apoplexy, phthisis, necrosis, fatty and fibrofatty degeneration of the 
placenta, etc., but which are most appropriately described as placental 
infarcts. 

These structures vary materially in size, shape, and appearance, and 
are best described under the following headings: 

1. Small, whitish, or yellowish fibrous formations occurring upon 
either the foetal or maternal surface of the placenta, and varying in 
size from areas hardly visible to the naked eye to those having a diameter 
of several centimeters. These rarelv attain a thickness of more than 
a few millimeters, and are sharply differentiated from the surrounding 
placental tissue. 

2. Wedge-shaped or irregularly round areas of varying size in the 
interior of the placenta. These are usually dull white in color, exhibit 
a striated, fibrous appearance, and present a striking contrast to the 
normal tissue surrounding them. 

3. Less commonly, considerable portions of the placenta are involved 
in the process, and occasionally one or more cotyledons are converted 
into a pale white, dense, more or less fibrous tissue. In other instances 
a large portion of the organ may be involved in the change, one half 
and sometimes nearly its entire substance being implicated. 

4. A broad rim of opaque, whitish, or yellowish-white material may 







678 


DISEASES AND ABNORMALITIES OF THE OVUM 


extend for a varying distance around the margin of the foetal surface of 
the placenta, and occasionally forms a complete ring around it— pla¬ 
centa marginata. These bands vary from a few millimeters to several 
centimeters in breadth. They lie beneath the amnion and rarely attain 
a thickness of more than a few millimeters, except at the extreme margin 
of the placenta, where it merges into the membranes. In a certain num¬ 
ber of cases the band, instead of being situated at the margin of the 
placenta, lies somewhere between it and the center of the organ, thus 
forming a broad zone more or less parallel to the periphery, but sep¬ 
arated from it by apparently normal placental tissue. To this condition 
the term margo placentae is sometimes applied. 

5. Pinkish or brickdust-colored, irregularly shaped, more or less 
solid masses, sharply marked off from the surrounding tissue, may 
occupy a larger or smaller portion of the placenta. They are usually 
most prominent on the maternal surface, and frequently extend through 
its entire thickness; they are sometimes termed red infarcts. 

6. Somewhat more frequently, roundish areas varying from bright 
red to almost black in color, and measuring from one to three centi¬ 
meters in diameter, are scattered through the substance of the placenta. 
They are composed almost entirely of blood, and are sharply differ¬ 
entiated from the surrounding tissue by a capsule which presents a 
whitish and fibrous appearance. When they occur in considerable num¬ 
bers, the entire placenta is studded with them, presents a nodular sur¬ 
face, and on section an appearance which Pinard has aptly described as 
placenta truffe. 

These structures are also designated as red infarcts, though many 
authors prefer to speak of apoplexy or hematoma of the placenta. They 
differ markedly in structure and appearance from the other form of 
so-called red infarcts, and probably have nothing in common with 
them. 

Frequency .—Minute white infarcts are present in every placenta, 
while I found similar areas, measuring 1 centimeter or more in diameter, 
in 63 per cent, of 500 consecutive placentae. If not present in excessive 
numbers, such infarcts possess no clinical significance, and according 
to the researches of Eden and myself are to be regarded as signs of 
senility of the organ. On the other hand, when they are of large size 
and abundant, they may mechanically throw out of function so great a 
portion of the placenta as seriously to interfere with the nutrition of the 
foetus, and sometimes cause its death. 

On the other hand, McNalley and Dieckman in carefully studying 
a series of 320 placentae, noted hemorrhagic lesions in 38 per cent., of 
which somewhat more than one-third corresponded to the structures de¬ 
scribed under heading 6. 

Mode of Formation .—According to Clemenz four main views have 
been advanced in explanation of the formation of the usual type of white 
infarct: 1, placentitis; 2, peri- and endarteritis of the villous vessels; 
3, changes in the decidua; and 4, the obliteration of maternal vessels. 
He considers that view 1 possesses only an historical interest, that views 
2 and 3 are untenable, while view 4 affords the only reasonable ex- 



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PLACENTAL INFARCT FORMATION. X 60. 

Fig. 1.—Fully developed infarct. 

Fig. 2. —-Chorionic villi, showing endarteritis and formation of canalized fibrin. B., blood 
in intervillous spaces; C. F., canalized fibrin; End., arteries showing obliterating en- 
d ar t e r iti_ _■— 








DISEASES OF THE PLACENTA 


679 


planation. On the other hand, the researches of Ackermann, Orth, 
Eden, Kermauner, and myself, indicate that the usual type of infarct 
formation is the result of obliterating endarteritis in the vessels of the 
chorionic villi, and is brought about in the following manner: As soon 
as the circulation through the arteries of the chorionic villi is interfered 
with by the endarteritic process, necrotic changes begin to appear at 
their periphery (Plate XIV, Fig. 2). Owing to the fact that the 
syncytium is nourished in part by the maternal blood, the changes 
occur first in the layer of tissue just beneath it, and manifest them¬ 
selves as coagulation necrosis of the tissue which has replaced Lang- 
hans ? layer of cells. As the process becomes more marked, this is 
gradually converted into the so-called canalized fibrin. A little later the 
syncytium undergoes a similar change, the fibrin then coming in direct 
contact with the maternal blood in the intervillous spaces. As a con¬ 
sequence, the blood immediately adjoining the necrotic tissue coagulates 
with eventual fibrin formation. 

When similar changes occur in several adjacent villi, the maternal 
blood lying between them undergoes coagulation, so that eventually a 
number of villi become fused together by fibrin. A little later the 
stroma cells of the implicated villi undergo coagulation necrosis, and 
finally the conversion into fibrin becomes so extensive that large areas 
are produced in which only the shadows of degenerated villi can be 
distinguished (Plate XIV, Fig. 1). Ultimately the outlines of the 
villi disappear, and the entire mass takes on a homogeneous fibrinous 
appearance, in which it is impossible to distinguish the component parts. 
For full particulars concerning the process, the reader is referred to my 
monograph upon the subject. 

Less frequently another type of white infarcts is observed, which, 
for ease in differentiation, I designate as atypical infarcts, and which 
differ from those just described by- the relative absence of fibrin and 
of changes in the villous vessels. In this event the villi are closely 
packed together, and there is little or no development of fibrin between 
them. The syncytium remains intact for a long time, while the stroma 
soon presents a necrotic appearance; finally the syncytium becomes im¬ 
plicated and a fibrous mass results in which the pale outlines of villi 
are long distinguishable. While I cannot express a definite opinion as 
to their mode of origin, it is possible that Young and Clemenz are correct 
in attributing such infarcts to the occlusion of maternal vessels supply¬ 
ing isolated areas of the placenta. 

Sfameni states that placenta marginata is noted in 15 or 20 per 
cent, of all after-births, and is inclined to attribute its origin to me¬ 
chanical factors. 

Red infarcts of the placenta are less frequently observed. The type 
described in section 6 is sometimes associated with albuminuria on the 
part of the mother, which was present in 33, 60, and 67 per cent, of 
the cases collected by Cagny, Eossier, and Martin respectively. Unlike 
white infarcts, they may possess considerable clinical significance and, 
when well marked, may be associated with imperfect development of the 
foetus, and sometimes cause its death; although McXalley and Dieck- 








680 


DISEASES AND ABNORMALITIES OF THE OVUM 



mann deny such an association. They attribute them to hemorihage 
into the substance of the placenta resulting from interference w ith the 
maternal circulation, and believe that as they become organized they 
are converted into structures indistinguishable from the ordinary white 
infarct. With the latter point I agree; but, if one holds that the inter¬ 
villous spaces are normally filled by circulating maternal blood, it is 
difficult to conceive how isolated hemorrhage can occur into them. 

The mode of production of these interesting formations is in uigent 
need of elucidation, but, until it is forthcoming, I must confess my 
ignorance, and can make only one positive statement concerning them, 
and that is that they are not, as a rule, observed in the placentae of 

eclamptic women, being noted only in a certain proportion of patients 

suffering from pro¬ 
nounced nephritic 
toxemia. 

Cysts of the 
Placenta. — Cystic 
structures are fre- 
quently observed 
upon the foetal sur¬ 
face and occasion¬ 
ally in the depths 

of the placenta. 

Small cysts a few 
millimeters in di¬ 
ameter were noted 
in 56 per cent, 

of the placentae 

studied by Ker- 
mauner. Larger 
ones, occasionally 
attaining the size 

Fig. 499. — Cyst of Placenta (Ehrendorfer). X of & lemon, are ob¬ 

served but rarely. 

In one of my specimens, five cysts varying from 3 to 5 cm. in diameter, 
projected from the foetal surface of the placenta. 

Such cysts are derived from the chorionic membrane, as is shown by 
the fact that the amnion can be readily stripped off from them. Their 
contents are usually clear and transparent, but are sometimes bloody or 
grumous in character. The walls, especially the portions adjacent to 
the intervillous spaces, are lined in great part by a dull whitish mem¬ 
brane, while occasionally a portion is occupied by a white infarct. 

On microscopic examination, the lining membrane is found to be 
made up of one or more layers of tolerably large epithelial cells with 
round vesicular nuclei, which frequently present various degrees of de¬ 
generation. Here and there, corresponding to the situation of a white 
infarct, the cells are absent and the wall consists of fibrin. The re¬ 
searches of Ehrendorfer, Peiser, De Jong, Yassmer, and Schickele have 
plearly shown that the cells in question correspond to those of Langhans 5 









DISEASES OF THE PLACENTA 


681 


layer, and that the cysts result from the degeneration of masses of 
trophoblastic tissue. 

The cysts occurring in the depths of the placenta rarely exceed 1 
centimeter in diameter. They frequently occupy the center of an in¬ 
farct, are filled with grumous contents, and were mistaken by the older 
writers for abscesses. In other cases the contents are clear. Such struc¬ 
tures may be derived in one of two ways: either by the softening and 
breaking down of an infarct, the cyst-wall then consisting of fibrin; or 
more frequently from the degeneration of the trophoblastic cells which 
make up most of the so-called “decidual islands or septa.” In the latter 
case the walls are composed of cells identical with those observed in 
the cysts occurring upon the foetal surface of the placenta. 

So far as present experience goes, cystic formations, whether occur¬ 
ring upon the foetal surface or in the depths of the placenta, are of 
interest purely from a pathological point of view, and exert little or no 
influence upon the course of pregnancy or labor. 

Tumors of the Placenta.—John Clarke in 1798 described a solid 
tumor about the size of a man’s fist, which made up a large part of the 
placenta. In recent years a number of tumors, varying in size from that 
of a pea to that of a man’s fist, have been described. Dienst and Nebesky 
in 1903 and 1914, respectively, were able to collect 48 and 79 cases from 
the literature. 

According to Virchow, the most frequent variety of placental tumor 
is the myxoma fibrosum, which is composed in great part of fibrous 
tissue having abundant oval nuclei, with typical myxomatous areas scat¬ 
tered through it, but in my experience the so-called angio-chorioma is 
much more frequent. Until recently the placental tumors have been 
variously designated, and the 36 examples collected by Albert were 
classified as follows: 


Myxoma fibrosum. 14 

Fibroma. 10 

Angioma. 9 

Sarcoma. 2 

Hyperplasia of chorionic villi. 1 


The researches of Dienst, Pitha, and Nebesky, however, show that 
they are practically all of one type, and consist of masses of chorionic 
villa with immense hypertrophy and hyperplasia of the terminal vessels, 
so that they may be designated as chorio-angiomata. Dienst suggested 
that they be designated as chorioma angiomatosum, or fibrosum, accord¬ 
ing as dilated vessels or connective tissue predominate. In many in¬ 
stances the tumor is connected with the chorion by a small pedicle, in 
which an artery and vein can usually be distinguished, and Pitha holds 
that the etiological factor is to be sought in interference with the 
circulation in these vessels. 

As the chorio-angiomata do not affect the surrounding placental tis¬ 
sue, they do no harm unless they involve so considerable an area as to 
throw a large part of the placenta out of function. Albert, on the other 
hand, holds that they exert a deleterious influence upon the course of 











682 


DISEASES AND ABNORMALITIES OF THE OVUM 


pregnancy and labor. I have observed approximately twenty chorio- 
angiomata, and also had an opportunity to study another specimen, 
which Dr. Cary of Brooklyn was kind enough to send. In this instance, 
the stroma of the large tumor was so rich in cells that I was tempted 
to diagnosticate it as a sarcoma of the placenta, but I now feel that ii 
differed from the relatively common angiochorioma only in the relative 
absence of blood vessels. 

Walz in 1906 described a number of multiple tumors in the placenta 
presenting a structure typical of myxosarcoma. These he considered 
were metastases from a similar tumor in the leg, which had originated 
during pregnancy. Senge a few years later described a carcinomatous 
growth in the placenta, which he regarded as a metastasis from a car¬ 
cinoma of the stomach. These observations are of great interest, in thai 
they forcibly illustrate the connection of the intervillous spaces with tin 
general maternal circulation. 

Inflammation of the Placenta.—Under the term placentitis many of 
the older writers described changes which we now recognize as infarcl 
formation. Moreover, as has already been said, small placental cysts 
filled with grumous contents were formerly thought to be abscesses, 
Hence it follows that most of the statements in the abundant earl) 
literature upon inflammatory lesions of the placenta must be received 
with the greatest caution. At the same time acute inflammation of 
the placenta is occasionally met with. It is not a primary condition, 
but is usually due to the extension of a similar process from the decidua, 
resulting from an exacerbation of a preexisting chronic gonorrhea, oi 
from an acute infection due to the gonococcus or other pyogenic bacteria. 
Very exceptionally, abscess formation may be a manifestation of a gen¬ 
eral infection originating in any portion of the body. 

In cases of prolonged labor, as will be elaborated in Chapter XXXI, 
Slemons has shown as the result of intrapartum infection that pyogenic 
bacteria may invade the foetal surface of the placenta, and, after gaining 
access to the intervillous spaces, give rise to general infection of the 
foetus. 

Frequently, upon examining sections of placental tissue under the 
microscope, I have found the decidua serotina infiltrated with leukocytes 
and presenting the characteristic picture of an acute inflammation, while 
the adjacent intervillous spaces were crowded with leukocytes. Franque 
observed similar conditions, but is inclined to believe that in most in¬ 
stances the implication of the placenta is secondary to the death of the 
foetus. 

Tuberculosis of the Placenta.—Tubercle formation in the foetal por¬ 
tion of the placenta is extremely infrequent. For particulars the reader 
is referred to the chapters upon the Physiology of the Foetus and upon 
the Infectious Diseases Complicating Pregnancy. 

Calcification of the Placenta.—Small calcareous nodules, sometimes 
occurring in the form of flat plaques, are frequently observed upon the 
maternal surface of the placenta, and are occasionally so abundant as to 
give to the finger the same sensation as when feeling a piece of coarse 
sand-paper. Frankvl showed that the chalky material was usually de- 




ABNORMALITIES OF THE UMBILICAL CORD 


683 


posited in the necrotic tissue surrounding the ends of the “fastening*’ 
villi, as well as in the superficial layers of the decidua serotina. 

\\ hen the widely spread occurrence of degenerative changes in the 
placenta is remembered, it should be a matter of surprise, not that calci¬ 
fication is occasionally met with, but rather that it is not noted in almost 
every placenta, inasmuch as apparently ideal conditions for its forma¬ 
tion are constantly present in the later months of pregnancy. 

Abnormal Adherence of the Placenta.—In the vast majority of cases 
the term adherent placenta is a misnomer, since the interference with its 
expulsion is usually due to abnormalities in the uterine contractions 
rather than to abnormal adhesions between it and the uterine wall. In 
rare instances, on the other hand, the adhesions may be so firm and 
extensive that separation cannot be effected spontaneously, and even at 
autopsy is possible only by tearing either the placenta or the uterine wall. 

Neumann, Hense and Schweitzer have examined uteri in which this 
condition obtained. Microscopic examination showed that the decidua 
serotina was almost entirely absent, and that the chorionic villi had 
deeply invaded the uterine wall and penetrated between the individual 
muscle fibers. Schweitzer's article is accompanied by excellent illustra¬ 
tions, and reviews the literature up to 1918. 


ABNORMALITIES OF THE UMBILICAL CORD 





Variations in Insertion.—The umbilical cord is usually inserted ec¬ 
centrically upon the foetal surface of the placenta, somewhere between 
its center and peri¬ 
phery. A central 
insertion is less 
common, while in a 
still smaller num¬ 
ber of cases the 
junction has taken 
place near the mar¬ 
gin, giving rise to 
a condition known 
as battledore pla¬ 
centa. 

In a series of 
2,000 placentae, 
which I studied in 
this regard, the in¬ 
sertion was eccen¬ 
tric in 73 per cent., 
central in 18 per 

cent., and marginal in 7 per cent. These variations possess no clinical 
significance. 

On the other hand, the so-called velamentous insertion of the cord — 
insertio velamentosa—is of considerable practical importance. In this 


Fig. 500. 


Marginal Insertion of the Cord. Battledore 
Placenta. 








G84 


DISEASES AND ABNORMALITIES OF THE OVUM 


condition the vessels of the cord separate some distance from the pla¬ 
cental margin and make their way to the latter in a fold of amnion (Fig. 
500). This mode of insertion was noted in 0.84 per cent, of 15,891 
placentae examined by Lefevre, and in 1.25 per cent, of our cases. Ac¬ 
cording to Mironoff it occurs nine times more frequently in twin than 
in single pregnancies, being noted in 5 and 0.57 per cent, of the cases 
respectively. 

Its mode of production has given rise to a great deal of speculation. 
So long as the old views were in vogue concerning the part played by the 
allantois and the amnion in the formation of the umbilical cord, 
Schultze’s explanation obtained almost universal acceptance. According 
to this, the anomaly was the result of abnormal adhesions between the 
umbilical vesicle and the chorionic membrane, whereby the amnion was 
prevented from applying itself in the usual manner to the cord. At pres¬ 
ent, however, this explanation is not regarded as satisfactory, as it is 
now recognized that the allantois plays an insignificant part in the for¬ 
mation of the cord in human beings. 

According to Franque, the abdominal pedicle ordinarily extends to 
the foetus from that portion of the chorion which is in contact with the 
most richly vascularized portion of the decidua—usually the decidua 
serotina—so that the cord becomes inserted upon the placenta. Occa¬ 
sionally, however, during the first few days of pregnancy, the area of 
greatest vascularization may be in the decidua reflexa, and in such cir¬ 
cumstances the abdominal pedicle takes its origin from that location. 
With the advance of pregnancy, however, the area of vascularization 
eventually shifts to the decidua basalis—the site of the future placenta 
—while the abdominal pedicle retains its original position, and from its 
maternal end the vessels extend to the placental margin. The correct¬ 
ness of this explanation was endorsed by Ottow in 1922. 

When the placenta is inserted low down in the uterus, the velamen- 
tous vessels may extend partially across the internal os —vasa previa — 
and as dilatation progresses be pressed upon by the presenting part, the 
interference with the circulation causing asphyxia of the foetus. In rare 
cases such vessels are torn through when the membranes rupture, and the 
foetus bleeds to death. The full literature upon this subject up to 1898 
has been collected by Peiser. 

Variations in Length of Cord.—Normally, the umbilical cord 
averages about 55 centimeters in length, though it may present marked 
variations—3.5 to 198 centimeters (Dyhrenfurth and Hyrtl). In rare 
instances it may be so short that the abdomen of the foetus is in contact 
with the placenta, but under such circumstances a congenital umbilical 
hernia is always present. 

According to Kaltenbach the cord must be of a certain length in order 
to permit of delivery of the child—that is, it must be sufficiently long 
to reach from its placental insertion to the vulva, 35 centimeters when 
the placenta is inserted high up, and 20 centimeters when low down; 
while Gardiner places the limit at 32 centimeters. 

On the other hand, it sometimes happens that cords, which actually 
exceed the normal in length, may be so twisted about the child as to 


ABNORMALITIES OF THE UMBILICAL CORD 


685 


become practically too short. When a coil encircles the neck, Gardiner 
estimates that the cord must measure 76 or 101 centimeters in length 
in vertex and breech presentations, respectively, if it is not to exert trac¬ 
tion upon the placenta. Accordingly, one distinguishes between absolute 
and relative shortness of the cord. Either of these conditions may give 
rise to dystocia. Brickner, who has carefully studied the subject, states 
that delivery cannot occur under such circumstances unless one of the 
following accidents occur: separation of the placenta, inversion of the 
uterus, umbilical hernia of the foetus, or rupture of the cord, the last 
two being of infrequent occurrence. 

Rupture of the cord may result from absolute or accidental shortness, 
being due to the former in DyhrenfurtlTs, and to the latter in Ahlfeld’s 
case, in which the cord measured 44 centimeters in length, but was tightly 
twisted about the foetus. Ordinarily an excessively long cord exerts no 
deleterious influence, although it predisposes to the formation of loops 
during pregnancy and to prolapse at the time of labor. 

Knots of the Cord.—It is customary to distinguish between false and 
true knots, the former being due to developmental abnormalities in the 
cord, while the latter result from the active movements of the child. True 
knots occur very frequently, and occasionally are of the most complicated 
character. Ordinarily they are of no clinical importance, but occasionally 
they may be pulled so taut as to compress the vessels and lead to asphyxia 
of the foetus. 

Loops of the Cord.—The cord frequently becomes wrapped around 
portions of the foetus, and in every third or fourth case of labor the 
child’s neck will be found loosely encircled by one or more loops. In 
rare instances these may produce strangulation. Most of these accidents 
are not due to any drawing taut of the loop, but rather to the fact that 
it does not become looser in proportion as the neck of the child increases 
in size. In other cases loops of the cord may so tightly encircle the body 
or one of the extremities of the child as to give rise to deep depressions, 
which in extreme cases may eventuate in the strangulation or gangrene 
of the affected part. 

In single-ovum twins, in which the amniotic partition wall has already 
been broken through, it sometimes happens that the cord of one foetus 
may become wrapped around some portion of the other so tightly as to 
cause its death. A number of cases of this character have been collected 
by Hermann. 

Torsion of the Cord.—As the result of movements on the part of the 
foetus, the cord may become more or less twisted. Occasionally the 
torsion is so marked as to interfere seriously with the circulation. The 
most extreme degrees occur only after the degth of the foetus, Schauta 
having reported a ease in which 380 twists were noted. In rare instances 
separation of the cord is produced, though this is possible only after the 
death of the foetus in the early months of pregnancy. 

Inflammation of the Cord.—As long as the child is alive inflammatory 
conditions are rarely noted, but after its death the whartonian jelly may 
be found infiltrated with leukocytes. Particularly in syphilis, obliterative 
changes occur in the vessels, the lumina becoming almost completely oc- 






686 


DISEASES AND ABNORMALITIES OF THE OVUM 


eluded, with leukocytic infiltration of the spaces between the muscle 
fibers, as well as in the adventitia. While suggestive, such changes are 
not pathognomonic of syphilis. 

Varices of the Cord.—In rare instances varices of the cord may rup¬ 
ture as the result of undue pressure. Meier has reported a case in which 
the death of the foetus was attributable to such an accident. 

Tumors of the Cord.—Tumor formations implicating the cord are 
rarely seen. Hematomata occasionally result from the rupture of a 
varix with subsequent effusion of blood into the cord. In one instance 
I observed such a tumor, 5 centimeters in diameter, at the foetal end of 
the cord. Myxomata and myxosarcomata have also been described. 
Winckel has reported two cases of sarcoma of the cord, while Budin has 
described a typical dermoid. The cases of Meyer and Haendly were of 
peculiar interest. In both instances a typical teratoma, the size of a 
child’s head, containing derivatives of all three germ layers, originated 
from the cord ten centimeters beyond its foetal insertion. 

Cystic structures occasionally occur in the course of the cord, and 
are designated as true and false cysts respectively, according to their 
mode of origin. The former are always quite small and, according to 
Kleinwachter, may be derived from remnants of the umbilical stalk or 
of the allantois; while the latter may attain a considerable size and 
result from liquefaction of the whartonian jelly. Haas has collected the 
literature concerning the latter variety up to 1906. As a rule such cysts 
are only apparent, and result from the liquefaction of the myxomatous 
tissue of the cord. 

Edema of the Cord.—This condition is rarely noted by itself, but is 
frequently associated with edematous conditions of the foetus. It is very 
common in dead and macerated children. In one of my cases, in which 
the child was born alive at full term, the cord was 3 centimeters in 
diameter and resembled an eel in appearance. Microscopic examination 
showed that the condition was simply due to an increase in the amount 
of whartonian jelly. 

DISEASES OF THE FCETUS 

Foetal Syphilis.—Syphilis is the most frequent cause of foetal death 
in the later months of pregnancy, and is usually maternal in origin. 
The mother may be suffering from the disease at the time of conception, 
or may contract it during the course of pregnancy, but in either event 
transmission to the foetus occurs through the placenta. Contrary to the 
present trend of opinion, as was stated in Chapter XXV, I believe that 
in rare instances the disease may be paternal in origin, and is transmitted 
in some way by the spermatozoa. In such cases the mother will or will 
not contract the disease according as the father does or does not pre¬ 
sent infectious lesions at the time of coitus. Since these are usually 
absent, the mother escapes, while the foetus ordinarily becomes inoculated 
— Colies’ law. Indubitable evidence of paternal transmission will be 
lacking until the existence of some “sporal” form of the spirocheta pal- 











DISEASES OF THE FOETUS 


687 


lida lias been demonstrated, as has been done with the spirochete causing 
recurrent fever. 

It has long been known that a syphilitic infection exerts a most 
deleterious influence upon the product of conception. In 1915 I stated 
that it was the most important single factor concerned in the production 
of foetal death in hospital practice, and in 1920 I demonstrated that it 
was responsible for 34 per cent, of 302 consecutive foetal deaths in our 
service. Usually it leads to the untimely expulsion of a macerated pre¬ 
mature foetus. Less commonly the child is born alive showing distinct 
manifestations of the disease, while in other cases they do not appear 
until a later period. It should, however, be remembered that no evi¬ 
dence has been adduced to show that syphilis plays any part in the 
production of abortion. 

It is of the greatest importance that the practitioner should become 
thoroughly familiar with the characteristic lesions of foetal and placental 
syphilis, as upon their recognition the future treatment of the patient 
often depends. This is a point especially worthy of emphasis, inasmuch 
as, in consequence of ignorance or design on the part of one or both 
parents, the first intimation that the physician may have of the existence 
of the disease is often afforded by the birth of a dead child, or the 
appearance of syphilitic stigmata in a living one; unless the Wassermann 
reaction is determined in all pregnant women—a procedure which is 
possible only in well regulated hospitals. 

Syphilis not only gives rise to characteristic lesions of the foetus, but 
also affects the placenta, so that frequently a diagnosis can be made 
from an examination of the latter organ. This fact is of special impor¬ 
tance in those cases in which the foetus is born alive, or when an autopsy 
is not permitted upon a dead child. The appearance of the syphilitic 
foetus varies materially according as it is born alive or dead. In either 
instance it is markedly undersized, and the subcutaneous fat is poorly 
developed or entirely lacking. In the living child the skin usually pre¬ 
sents a dry, drawn appearance, and has a peculiar grayish hue. It is 
very brittle, especially at the flexor surfaces of the joints, where abrasions 
readily occur and expose the underlying corium. The skin covering the 
soles of the feet and palms of the hands is often thickened and glistening, 
and suggests the condition observed in the hands of washerwomen. In 
other cases, characteristic pemphigoid vesicles are noted in the same 
locations. 

If intra-uterine death has occurred, the foetus rapidly undergoes 
maceration, the skin peeling off upon the slightest touch and exposing 
the underlying discolored corium. Although Grafenburg states that 80 
per cent, of macerated children are syphilitic, maceration is by no means 
pathognomonic, since it occurs whenever a dead foetus is long retained 
in utero, no matter what the cause of death. 

The lesions in the internal organs consist essentially in interstitial 
changes in the lungs, liver, spleen, and pancreas, and osteochondritis in 
the long bones. 

It is generally stated that the lungs frequently contain gummatous 
nodules. These, however, were lacking in the specimens which I have 






GS8 


DISEASES AND ABNORMALITIES OF THE OVUM 


examined. Usually the lungs are enlarged, pale, and scarcely float when 
thrown into water. On microscopic examination the alveoli are found 
filled with cast-off epithelial cells in all stages of fatty degeneration— 
catarrhal pneumonia, the pneumonia alba of Virchow. In other cases • 
the lesion consists in an increase in the interstitial tissue associated with 
pronounced round-cell infiltration, by which the alveoli are compressed, 
but do not become quite impervious to air. These changes have been 
exhaustively studied by Heller. 

As the result of hypertrophic cirrhosis, the liver undergoes a marked 
increase in size, and, according to Ruge, its weight may equal one tenth 
or even one eighth of that of the whole body, instead of one thirtieth, as 
usual. Under the microscope there is a marked increase in the con¬ 
nective tissue surrounding the individual lobules and acini, with here 
and there small areas of round-cell infiltration. Many authorities lav 
great stress upon the presence of so-called blood islands—dilated capil¬ 
laries containing red cells in all stages of development—but in my expe¬ 
rience the condition is not pathognomonic. 

The spleen likewise undergoes interstitial changes and increases 
markedly in size, so that it frequently weighs two or three times as 
much as usual, which, roughly speaking, is one three-hundredths of the 
body weight. The pancreas also presents interstitial changes, and is 
slightly larger than normal. 

Prior to the middle of pregnancy, Tissier and Girauld state that 
the Spirochaeta pallida is rarely found, but after that period the foetus 
may be said to suffer from a spirochetal septicemia when the parasites 
may be demonstrated in large numbers in the various organs and blood. 
They are most abundant in the adrenals, where they are noted in 97.5 
per cent, of all cases, according to Trinchese, and progressively less 
frequently in the following organs: lungs, pancreas, liver and internal 
genitalia. 

The recognition of the organic lesions requires some pathological 
experience, though if the liver and spleen of a macerated foetus are 
markedly increased in size and weight the diagnosis is practically as¬ 
sured. 

An equally characteristic sign, and one which is readily detected, is 
afforded by changes occurring at the junction of the epiphysis with the 
diaphysis in the long bones—Wegner’s bone disease. Normally the two 
are separated by a narrow, whitish, slightly curved line, 0.5 to 1 milli¬ 
meter in diameter—Guerin’s line—representing the zone of preliminary 
calcification, which constitutes the scaffolding upon which the new bone 
is developed. In syphilis, on the other hand, this becomes converted into 
an irregular, jagged, yellowish zone 2, 3, or more millimeters in thick¬ 
ness. In advanced cases this alteration is associated with considerable 
softening and the formation of a soft pultaceous material, which some¬ 
times leads to complete separation of the epiphysis (Figs. 501 and 502). 

Upon microscopical examination of the normal epiphysis, as shown 
in Fig. 503, the cartilage cells are found to be arranged in parallel col¬ 
umns at right angles to Guerin’s line, while below it is the typical bony 
structure of the diaphysis with its marrow cavities. The line itself is 


DISEASES OF THE FCETUS 


689 


foimed by a deposit of lime salts between the median ends of the rows 
of cartilage cells, and is gradually invaded by the newly formed bone. 

In syphilis, as is illustrated in Fig. 504, the changes are due to an 



Fig. 501. Fig. 502. 

Figs. 501, 502. —Normal and Syphlitic Fcetal Epiphysis. X 2. 


osteochondritis, as the result of which there is no longer a sharply 
marked zone of preliminary calcification between the cartilage and the 
growing bone; but areas of bone formation, 
calcification, and leukocytic and small-cell 
infiltration are found scattered irregularly 
through the lower portion of the epiphysis, 
giving an irregular appearance to this region. 

These changes, which have been carefully 
studied by Wegner, and K. Muller, are most 
readily recognizable at the lower end of the 
femur, and fairly well so at the lower ends 
of the tibia and radius. They are extremely 
characteristic, and their detection justifies 
one in making a positive diagnosis and plac¬ 
ing the mother under specific treatment. 

Alexander has shown that the osseous lesions 
are widely diffused, occurring at the epi¬ 
physes of all the long bones, as well as in the 
phalanges of the hands and feet. Since the 
demonstration by Shipley and Pearson that 
the changes can readily be recognized by 
means of the X-ray, we have utilized the 
procedure as an accessory means of diagnosis. 

Accordingly, we take X-ray pictures of all dead children as a matter of 
routine—partly for diagnostic purposes, but especially to permit com¬ 
parison between the X-ray and autopsy findings. Furthermore, they are 


. V • 




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: ? K} 

Vi .5. - 

4 * 


; —«.* 


r- -•> >. JJ 

•: v. -_ ciO 3 - 


&• 


.,*V 


V- 


a i. 

Trfci . ‘ S,. . * 

yf' . v* - - 


i'1%‘ -k" vV» * * ; v V,. ‘ -' 

H v- % $ is 1 ■ 





Fig. 503. — Normal Fcetal 

Epiphysis. X 60. 







690 


DISEASES AND ABNORMALITIES OF THE OVUM 


taken in the case of live children, whenever anything in the history sug¬ 



gests the possibility of the existence of syphilis. 

Three years’ experience has convinced me that the procedure consti¬ 
tutes a most valuable addition to our diagnostic equipment, and whenev ei 
lesions similar to those depicted in Fig. 505B are present that the 
diagnosis of syphilis is assured. 

Placental Syphilis.—Under the influence of syphilitic infection the 
platenta undergoes very characteristic changes. It becomes larger and 
paler in color, and often presents a dull, greasy appearance. It is always 

relatively, and frequently absolutely, increased in size, and, according 

to the researches of 

Schwab and Levy- 
Solal, which I have 
been able to confirm, 
instead of one sixth, 
it may represent as 
much as one fourth, 
or even a larger frac¬ 
tion, of the entire 
body weight of the 
foetus. 

Still more char¬ 
acteristic, however, 
are the changes in 
the chorionic villi, to 
which Frankel called 
attention in 1873. 
During the last 3 or 
4 months of preg¬ 
nancy when syphi- 

Fig. 501. —Syphilitic Fcetal Epiphysis. X 60. litic placentae are 

teased out in salt 

solution, the villi are seen to have lost their characteristic arborescent 
appearance and to have become thicker and more club-shaped (Figs. 506 
and 507). At the same time there is a marked decrease in the number 
of blood vessels, which in advanced cases have almost entirely disappeared. 
This results partly from endarteritic changes, but principally from a 
proliferation of the stroma cells, which lose their normal stellate appear¬ 
ance, becoming round or oval in shape, and closely packed together. 

The changes are still more characteristic when sections made from 
hardened specimens are studied. As will be seen on comparing Figs. 
508 and 509, the individual villi are increased in size and almost devoid 
of blood vessels, while their stroma is made up of closely packed, round, 
or oval cells. This appearance is so characteristic as to enable one with 
a little practice to make a positive diagnosis. In my experience, which 
is based upon the histological examination of many thousand placentae, 
such lesions are always associated with the presence of typical organic 
changes in the foetus. On the other hand, it must be admitted that 
negative placental findings do not necessarily imply the absence of 







DISEASES OF THE FCETUS 


691 




syphilis in the child. Consequently, the diagnosis is assured if the find¬ 
ings are positive, while a negative result is of no diagnostic significance. 
The lesions just described afford a satisfactory explanation for the poor 
development of the foetus when born alive, and in association with the 
spirochetal septicemia 

and the organic involve- a b 

ment readily explain the 
frequency of a fatal 
issue. 

On the other hand, 

Mohn, and others be¬ 
lieve that the changes 
just described, while 
very suggestive, are not 
absolutely characteris¬ 
tic ; and hold that a 
positive diagnosis can¬ 
not be made unless the 
presence of the spiro¬ 
chetes can be demon¬ 
strated in the placenta. 

This has been attempted 
by many investigators, 
who have found that 
the spirochetes are 
so sparsely scattered 
through the organ that 
their recognition is most 
difficult, even when they 
are present in large 
numbers in the foetal 
organs. Trinchese states 
that they can always be 
found, if one is willing 
to study several hun¬ 
dred sections, but in my 
clinic Pauli and Em¬ 
mons were not so suc¬ 
cessful. 

In my experience the 
demonstration of a posi¬ 
tive maternal Wasser- 

mann by no means implies the existence of foetal syphilis, as in 169 
women presenting a positive reaction, but not treated, who were studied 
in my report of 1920, only 48.5 per cent, had syphilitic children. 
Furthermore, a negative maternal Wassermann does not necessarily 
imply the absence of syphilis, and in the same report, it was stated 
that approximately every tenth syphilitic foetus w r as born of a mother 
whose Wassermann was negative. Consequently, it is particularly in 



Fig. 505, A and B.— X-Rays of Leg of Normal and 
Syphlitic Fcetus. X IT 

A. Normal. B. Syphilitic. Note the broad bands 
occupying the position of Geurin’s line. X /T 








692 


DISEASES AND ABNORMALITIES OF THE OVUM 


this type of ease that the X-ray and the histological examination of 
the placenta give valuable information, more especially if an autopsy 
is not permitted. Observations of this character emphasize the impor¬ 
tance of not relying exclusively upon the outcome of the Wassermann 
reaction in the diagnosis of syphilis, and make it apparent that the 
utilization of this valuable diagnostic procedure cannot replace accurate 
clinical observation, as so many are inclined to believe. 

For many years, it was our practice to make a routine Wassermann 
test upon the blood of the foetus obtained from the umbilical cord, and 
positive results were obtained in about one per cent, of approximately 
5,000 observations. Upon following such children during the first year 



Fig. 506. 


Fig. 507. 


Figs. 506, 507. —Normal and Syphilitic Chorionic Villi Teased Out in Salt Solu¬ 
tion, Slightly Magnified. 




of life, it was found that a considerable number, who presented a positive 
Wassermann at birth, subsequently showed a negative reaction and at no 
time developed clinical manifestations of syphilis; while, on the con¬ 
trary, in numerous other instances the original negative reaction sub¬ 
sequently became positive and was accompanied by signs of congenital 
disease. For these reasons, we have abandoned the practice, as the result? 
obtained did not seem commensurate with the time or expense consumed 
Fildes takes a similar view. 


Such a statement, however, should not be considered as in any way., 
invalidating the usefulness of the routine maternal Wassermann, as it 
is only by its means, and the subsequent intensive treatment of the 
mothers presenting a positive reaction that we can expect to cope suc¬ 
cessfully with the problem of foetal and congenital syphilis. 

It is generally stated that distinct syphilitic lesions, varying from a 
marked thickening of the membrane to distinct gumma formation, are 






DISEASES OF THE FGETUS 


693 


frequently noted in 
the decidua. I be¬ 
lieve, however, that 
many of the condi¬ 
tions described as 
such have no con¬ 
nection with lues, 
but represent vari- 
ous hyperplastic 
conditions. 

Zilles, and many 
of the earlier 
writers, described 
gummata occurring 
in the foetal portion 
of the placenta. I 
have never met with 
such lesions, and 
am of the opinion 
that careful 


logical study will 



show that the struc¬ 
tures designated as 
such are merely infarcts in various 


Fig. 508. —Normal Full-Term Placenta. X 50. 


stages 


of development or degen¬ 
eration. 

Bondi in 1903 
directed attention 
to changes in the 
umbilical cord, 
which he considered 
very characteristic, 
and his findings 
have been confirmed 
by most subsequent 
writers. These oc¬ 
cur in the vessels, 
and consist in 
edema of their 
walls, and leukocy¬ 
tic infiltration of 
the spaces between 
the muscle fibers. 
Similar changes are 
noted in the adven¬ 
titia, while the in- 
tima is more or less 
thickened. Mohn stated that he was able to demonstrate the presence 
of spirochetes in 50 per cent, of his cases, but subsequent study has 
shown that he was in error. They are sometimes present in the foetal 



Fig. 509. —Syphilitic Full-Term Placenta. X 50. 





694 


DISEASES AND ABNORMALITIES OF THE OVUM 


end, but only rarely in the rest of the cord. Trinchese in 100 cases 
found them in 18 instances in the former, but never in the latter 
location, and Emmons in my clinic had a similar experience. 

General Dropsy of the Foetus.—In this rare condition, which has 
been carefully studied by Ballantyne and Schumann, the foetus and 
placenta are markedly edematous. As the result of infiltration with 
serum the former may attain immense proportions and the latter be 
increased to three or four times its normal size. In a case under my 
observation the foetus, at the seventh month of pregnancy, weighed 1,140 
and the placenta 1,200 grams. Cohn has described a placenta weighing 
2,900 grams. 

Although a good deal has been written upon the subject, no satisfac¬ 
tory explanation of the anomaly has as yet been arrived at. Formerly 
it was supposed to result from edematous conditions of the mother, 
but the researches of Ballantyne have shown that this view does not 
always hold good, and that in the majority of the cases submitted to a 
thorough study lesions were noted in the organs of the foetus sufficient to 
explain the production of the condition. It is interesting to note that 
in several cases collected by Seifert it was attributed to foetal leukemia. 

The disease always leads to the death of the foetus, which in no 
instance survived its birth for more than a few hours. In the majority 
of cases on record labor was spontaneous, though occasionally the in¬ 
creased size of the foetus and the placenta may give rise to dystocia. 

Other Diseases of the Foetus.—In most text-books upon obstetrics 
numerous morbid conditions of the foetus are described under the head¬ 
ing Diseases of the Foetus. The majority of them, however, are of 
interest mainly from a pathological point of view, and have no obstetrical 
significance, except when they lead to an increase in the bulk of the 
foetus, which in turn may give rise to difficult labor. Accordingly, they 
will not be considered in this place, although certain of them will be 
referred to in the chapter upon Foetal Dystocia. 


LITERATURE 

Ackermann. Der weisse Infarct der Placenta. Archiv. f. path. Anat., 1884, xcvi, 
439-452. 

Zur. normalen u. path. Anat. der mensc-hlichen Placenta. Virchow’s Festschrift, 
Berlin, 1891, 585-616. 

Ahlfeld. Multiple Dermoidcysten des Amnion. Berichte u. Arbeiten, 1885, ii, 
200 - 202 . 

Die Verwachsungen des Amnion mit der Oberflache der Frucht. Berichte u. 
Arbeiten, 1887, iii, 158-165. 

Zerreissung der Nabelsehnur eines reifen Kindes wahrend de,r Geburt. Zeitschr. 
f. Geb. u. Gyn., 1897, xxxvi, 467-472. 

Aichel. Ueber die Blasenmole, eine experimentelle Studie. Habilitationsschrift, 
Erlangen, 1901. 

Albert. Ueber Angiome der Placenta. Archiv f. Gyn., 1898, lvi, 144-159. 

Alexander. Die ostealen Veranderungen bei kongenitaler Syphilis. Leipzig, 
1915. 




LITERATURE 


695 


Ballantyne. General Dropsy of the Foetus. The Diseases of the Foetus, Edin¬ 
burgh, 1892, i, 102-164. 

Bar. Recherches pour servir a l’histoire de 1 ’hydranmios. These de Paris, 1881. 

Bardeleben. Geburt bei Amnionanomalien. Zeitschr. f. Geb. u. Gyn., 1905, lvi, 
240-263. 

Birnbaum. Blasenmole bei einem Zwillingsei. Monatsschr. f. Geb. u. Gyn., 1904, 
xix, 175-186. 

Boivin, Madame. Nouvelles recherches sur la nature, l’origine et le traitement de 
la mole vesiculaire. Paris, 1827. 

Bondi. Die syphilitischen Veranderungen der Nabelschnur. Archiv. f. Gyn., 1903, 
Ixix, 223-246. 

Braun, G. Ligatur der Nabelschnur durch Amnionstrange. Zeitschr. d. Ges. f. 
Aertze zu Wien, 1854, ii, 192. 

Breslau und Eberth. Diffuses Myxom der Eihaute. Virchow’s Archiv, 1867, 
xxxix, 191-192. 

Brickner. A New Symptom in the Diagnosis of Dystocia Due to a Short Umbili¬ 
cal Cord. Amer. Jour. Obst., 1902, xlv, 512-521. 

Briggs. On the Relative Size of the Uterus in Cases of Hydatid Mole. Proc. 
Roy. Soc. Med., (Gyn. Sect.), 1912, v. 172-198. 

Briquel. Tumeurs du placenta et tumeurs placentaires. Paris, 1903. 

Budin. Note sur une tumeur du cordon ombilical. Femmes en couches et nouveau- 
nes, 1897, 179-184. 

Cagny. Hemorhagies placentaires de Ualbuminurie. These de Paris, 1891. 

Cary. Report of a Well Authenticated Case of Sarcoma of the Placenta. Am. 
J. Obst., 1914, lxix, 658-664. 

Chiari. The Relation of the Amnion to Human Malformations. Bull. Johns Hop¬ 
kins Hospital, 1911, xxii, 35-39. 

Clarke. Account of a Tumor found in the Substance of the Human Placenta. 
Philosophical Transactions, London, 1798. 

Clemenz. Kritische und historisclie Untersuchungen iiber die weisscn Nekrosen 
der Placenta. Zeitschr. f. Geb. u. Gyn., 1922, lxxxiv, 758-770. 

Cohn. Ueber das Absterben des Foetus bei Nephritis der Mutter. Zeitschr. f. 
Geb. u. Gyn., 1888, xiv, 596. 

Dienst. Ueber den Bau u. die Histogenese der Placentargeschwiilste. Zeitschr. 
f. Geb. u. Gyn., 1903, xlviii, 191-261. 

Dorland and Gerson. Cystic Disease of the Chorion. University Medical Maga¬ 
zine, May, 1896, 565-590. 

Durante. La mole hydatidiforme. Bull. Soc. d’obst. et de gynec. de Paris, 
1907, x, 244-49. 

Dyhrenfurth. Inversio uteri bedingt durch zu kurzen Nabelstrang. Zentralbl. 
f. Gyn., 1885, ix, 801, 804. 

Eden. A Study of the Human Placenta. Jour. Path, and Bacteriology, 1897, v, 
265-282. 

Ehrendorfer. Cysten und cystoide Bildungen der menschlichen Placenta. Wien, 
1893. 

Emmons. The Diagnostic Value of the Search for Spirochaeta Pallida in the 
Umbilical Cord of the New-born. Boston Med. and Surg. Jour., 1910, clxii, 
640-641. 

Essen-Moller. Studien iiber die Blasenmole. Wiesbaden, 1912. 

Fairbairn. Primary Chorio-Epithelioma of the Ovary. J. Obst. and Gyn. Brit. 
Emp., 1909, xvi, 1-8. 

Falgowski. Blasenmole bei Zwillungsschwangerschaft, etc. Monatsschr. f. Geb. 
u. Gyn., 1911, xxxii, 290-302. 





GOO 


DISEASES AND ABNORMALITIES OF THE OVUM 


Fehling. Ueber die physiologisehe Bedeutung des Fruchtwassers. Archiv f. 
Gy1879, xiv, 221-244. 

Fildes. The Prevalence of Syphilis Amongst the Newly-born, etc. J. Obst. & 
Gyn. Brit. Emp., 1915, xxvii, 124-137. 

Findley. Hydatidiform Mole. Am. Jour. Med. Sci., 1903, cxxv, 486-519. 

Primary Chorio-epithelioma Malignum Outside of the Placental Site. Jour. 
Am. Med. Ass., 1904, xliii, 1351-1357. 

Fraenkel. Die Histologic der Blasenmole, etc. Archiv f. Gyn., 1895, xlix, 481- 
507. 

Riickbildung von Ovarialtumoren nach Blasemole. Monatsschr. f. Geb. u. Gyn., 
1910, xxxii, 180-185. 

Frank. Chorion-epitheliomatous Proliferations in Teratomata. Jour. Am. Med. 
Ass., 1906, xlvi, 248, 343. 

Frankel. Ueber Verkalkungen der Placenta. Archiv f. Gyn., 1871, ii, 373-382. 

Ueber Placentarsypliilis. Archiv f. Gyn., 1873, v, 1-54. 

Franque. Anat. und klin. Beobachtungen iiber Plaeentarerkrankungen. Zeitschr. 
f. Geb. u. Gyn., 1894, xxviii, 293-348. 

Ueber histologische Veranderungen in der Placenta und ihre Beziehungen zum 
Tode der Frucht. Zeitschr. f. Geb. u. Gvn., 1897, xxxvii, 277-298. 

Die Entstehung der velamentosen Insertion der Nabelschnur. Zeitschr. f. Geb. 
u. Gyn., 1900, xliii, 463-488. 

Gardiner. Labor Complicated by Short or Shortened Cord. Surg. Gyn. and Obst., 
1922, xxxiv, 252-256. 

Gassner. Menge des Fruchtwassers. Monatsschr. f. Geburtsk., 1862, xix, 30-33. 
von Grafenberg. Observationes medicse rariores. Frankfurt, 1565. 

Grafenberg. Der Einfluss von Syphilis auf die Nachkommenschaft. Archiv f. 
Gyn. 1908, lxxxviii, 190-219. 

Haas. Beitrag zur Lehre von den Cysten der Nabelschnur. Beitrage zur Geb. 
u. Gyn., 1906, x, 483-507. 

Heller. Die Lungenerkrankungen bei angeborener Syphilis. Deutsches Archiv f. 
klin. Med., xliii, 159. 

Hense. Adharenz der Placenta. Zeitschr. f. Geb. u. Gyn., 1901, xlv, 272-279. 
Hermann. Ueber Verschlingungen der Nabelschniire bei Zwillingen. Archiv f. 
Gyn., 1891, xl, 253-260. 

Hormann. Ruptur eines Chorio-epithelioma mit schwerer intra-peritonealen Blu- 
tung. Beitrage zur Geb. u. Gyn., 1904, viii, 404-417. 

Zur Frage der Bosartigkeit und iiber Spontan-heilungen von Chorio-epitheliomen. 
Beitrage zur Geb. u. Gyn., 1904, viii, 418-447. 

Hubl. Ueber das Chorio-epitheliom in der Vagina bei sonst gesunden Genitalien. 
Wien. 1903. 

Hyrtl. Die Blutgefasse der menschlichen Nachgeburt. Wien, 1870. 

Jaggard. Note on Oligohydramnion. Amer. Jour. Obst., 1894, xxix, 432-446. 
Jarotsky und Waldeyer. Traubenmole in Verbindung mit dem Uterus, etc. 
Virchow’s Archiv, 1867, xli, 528-534. 

De Jong. Ueber das Entstehung von Cysten in der Placenta. Monatsschr. f. 
Geb. u. Gyn., 1900, xi, 1072-1092. 

Jungbluth. Zur Lehre vom Fruchtwasser. Archiv f. Gyn., 1872, iv, 554-557. 
Kaltenbach. Zu kurze Nabelschnur. Lehrbuch der Geb., 1893, 316. 

Kehrer. Ueber Traubenmolen. Archiv f. Gyn., 1894, xlv, 478-505. 

Kermauner. Zur Lehre von der Entwic-kelung der Cysten u. der Infarcte in der 
menschlichen Placenta. Zeitschr. f. Heilkunde, 1900, xxi, 1-36. 

Kleinwachter. Ein Beitrag zur Anatomie des Ductus omphalo-mesentericus. 
Archiv f. Gyn., 1876, x, 238-247. 





LITERATURE 


G97 


Klotz. Ein Fall von primaren Cliorioepitheliom des Ovariums. Beitrage zur 
Geb. u. Gyn., 1912, xvii, 369-373. 

Kossmann. Zur Geschichte .der Traubenmole. Archiv f. Gyn., 1900, lxii, 153-169. 
Krieger. Fall von interstitiellen Molenbildung. Berliner Beitrage zur Geb. u. 
Gyn., 1872, i, 10-15. 

Krosing. Das Chorio-epitheliom mit langer Latenzzeit. Archiv f. Gyn., 1909, 
lxxxviii, 469-505. 

Kustner. Ueber eine noch nicht bekannte Fntstehungsursache amputirender 
amniotischer Faden u. Strange. Zeitschr. f. Geb. u. Gyn., xx, 445-458. 
Larrier et Brindeau. Nature de la mole hydatidiforme. Revue de Gyn., 1908, 
xii, 203-214. 

Lebedeff. Quelques donnees sur la fonction physiologique de 1 ’amnios. Annales 
de gyn. et d’obst., 1878, ix, 241-251. 

Lefevre. De 1 ’insertion velamenteuse du cordon. These de Paris, 1896. 

Levison. Fruclitwasser und Hydramnios. Archiv f. Gyn., 1876, ix, 517-519. 
Levy. Rapports existant entre le poids du foetus et celui du placenta. These de 
Paris, 1900. 

Levy-Solal. Contribution a 1 ’etude des rapports de la syphilis et de 1 ’hyper¬ 
trophic placentale. Gyn. et Obst., 1921, iv, 94-118. 

Lukens. Hydatidiform Mole Associated with Normal Ovum, etc. Proc. Roy. 

Soc. of Med., (Gyn. Sect.), 1914, vii, 113. 

McNalley and Dieckmann. Hemorrhagic Lesions of Placenta and Their Rela¬ 
tions to White Infarct Formation. Am. Jour. Obst. and Gyn., 1923, v, 55-56. 
Marchand. Ueber die sogenannten ‘ ‘ decidualen ” Geschwiilste, etc. Monatsschr. 
f. Geb. u. Gyn., 1895, i, 419-438; 513-560. 

Ueber den Bau der Blasenmole. Zeitschr. f. Geb. u. Gyn., 1895, xxxii, 405-472. 
Die Blasenmole. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 206-216. 

Ueber das maligne Chorionepitheliom, nebst Mittheilung 2 neuen Falle. Zeitschr. 
f. Geb. u. Gyn., 1898, xxxix, 173-258. 

Martin. De 1 ’influence des alterations du placenta sur le developpement du foetus. 
These de Paris, 1896. 

Meyer. Teratom der Nabelschnur. Yerh. d. deutschen path. Gesellsch., 1914, 
582-583. 

Hydatidiform degeneration. Am. J. Obst. 1918, lxxviii, 641-668. 

Mohn. Die Veranderungen an der Placenta, bei Syphilis u. ihre Beziehungen zur 
Spirochaeta pallida. Zeitsch. f. Geb. u. Gyn., 1907, lix, 263-312. 
Montgomery. On the Spontaneous Amputation of the Foetal Limbs in Utero. 
An Exposition of the Signs and Symptoms of Pregnancy. 2d ed. (reprinted), 
1863, 625-695. 

Muller, R. Beitrag zur path. Anatomie der Syphilis hereditaria. Virchow’* 
Archiv, 1883, xcii, 523-556. 

Nebesky. Beitrag sur Kenntniss der Chorioangiome. Monatsschr. f. Geb. u. 
Gyn., 1914, xl, 42-52. 

Neumann. Beitrag zur Lehre von der Anwachsung der Placenta. Monatsschr. f. 
Geb. u. Gyn., 1896, iv, 307-318. 

Beitrag zur Kenntniss der Blasenmole, etc. Monatsschr. f. Geb. u. Gyn., 1897, 
vi, 17-36; 157-177. 

Nieberding. Zur Genese des Hydramnios. Archiv f. Gyn., 1882, xx, 310-316. 
Opitz. Beitrage zur Aetiologie des Hydramnios. Zentralbl. f. Gyn., .1898, 553- 

560. 

Orth. Infarct der Placenta. Lehrbuch der spec. path. Anat., 1893, ii, 603-607. 
Ottow. Interpositio velamentosa funiculi umbilicalis, etc. Archiv f. Gyn., 1922, 

cxvi, 176-199. 


698 


DISEASES AND ABNORMALITIES OF THE OVUM 


Ouvry. fitude de la mole hydatidiforme. These de Paris, 1897. 

Pauli. Placental Syphilis, etc. Bull. Johns Hopkins Hospital, 1908, xix, 326-28. 

Peiser. Verblutungstod der Frucht in folge Ruptur einer Umbilicalarterie bei 
Insertio velamentosa. Monatsschr. f. Geb. u. Gyn., 1898, viii, 619-624. 

Beitrag zur Pathologie der Placenta. Monatsschr. f. Geb. u. Gyn., 1899, x, 
613-626. 

Percy. Memoire sur les hydatides uterines, etc. Jour, de med., chir. et pharm., 
Paris, 1811, p. 171. 

Pick. Von der gut- und bos-artig metastasirenden Blasenmole. Berliner klin. 
Wochenschr., 1897, xxxiv, 1069-1073 ; 1097-1102. 

Pitha. Des tumeurs du placenta. Annales de gyn. et d’obst., 1906, 2me Ser., iii, 
232-239, 268-280, et 360-369. 

Poten. Die Verschleppung der Chorionzotten. Archiv f. Gyn., 1902, lxvi, 590-617. 

Poten und Vassmer. Beginnendes Syncytiom mit Metastasen, beobachtet bei 
Blasenmolenschwangerschaft. Archiv f. Gyn., 1900, lxi, 205-276. 

Ribemont-Dessaignes. Des placentas multiples dans les grossesses simples. An¬ 
nales de gyn. et d’obst., 1887, xxvii, 15-52. 

Ries. Chorionic Villi in the Uterine Wall 18 Years After the Last Pregnancy. 
Am. J. Obst., 1913, lxvii, 433-443. 

Risel. Ueber das maligne Chorion-epitheliom, etc. Leipzig, 1903. 

Das Chorio-epitheliom. Ergebnisse der allg. Path, und path. Anat., 1907. 

Zur Frage d. sogenanten primaren Chorioepithelioms des Ovariums. Verh. d. 
deutschen path. Gesellsch., 1914, 384-432. 

Rossier. Klin. und. histolog. Untersuchungen iiber die Infarcte der Placenta. 
Archiv f. Gyn., 1888, xxxiii, 400-412. 

Ruge. Ueber den Foetus sanguinolentus. Zeitschr. f. Geb. u. Gyn., 1877, i, 
57-119. 

Runge. Ueber die Ver'anderungen der Ovarien bei syncytialen Tumoren und 
Blasenmole, etc. Archiv f. Gyn., 1903, lxix, 33-70. 

Sallinger. Ueber Hydramnios, etc. D. I., Zurich, 1875. 

Sanger. Deciduoma malignum. Verh. d. deutschen Gesellsch. f. Gyn., 1892, iv, 
333. 

Sarcoma uteri deciduo-cellulare, etc. Archiv f. Gyn., 1893, xlix, 89-149. 

Santi. Zur Riickbildung der Luteinkystome nach Blasenmole. Zeitschr. f. Geb. 
u. Gyn., 1910, lxvii, 667-685. 

Schatz. Eine besondere Art von einseitiger Polyhydramnie, etc. Archiv f. Gyn., 
1882, xix, 329-369. 

Schauta. Zur Lehre von der Torsion der Nabelschnur. Archiv f. Gyn., 1881, 
xvii, 19-23. 

Scheib. Organveranderungen der polyhydramniotischen eineiigen Zwillinge. 
Chiari’s Festschrift, 1909, 51-78. 

Schickele. Die Chorionektodermwucherungen der menschlichen Placenta. Beitrage 
zur Geb. u. Gyn., 1905, x, 63-114. 

Schlagenhaufer. Zwei Falle von Tumoren des Chorionepithels. Weiner klin. 
Wochenschr., 1899, Nr. 18. 

Ueber das Vorkommen chorionepitheliom- und traubenmolen-artigen Wucherun- 
gen in Teratomen. Wiener klin. Wochenschr., 1902, Nos. 22 and 23. 

Schmidt. Ein neuer Fall von primaren Chorio-epitheliom der Scheide. Zentralbl. 
f. Gyn., 1901, xxv, 1350. 

Schmorl. Demonstration eines syncytialen Scheidentumors. Zentralbl. f. Gyn., 
1897, xxi, 1217. 

Schultze. Die genetische Bedeutung der velamentalen Insertion des Nabel- 
stranges. Jenaische Zeitschr. f. Med. u. Naturwiss., 1867, iii, 198. 




LITERATURE 


699 


Ueber velementale u. placentale Insertion der Nabelschnur. Archiv f. Gyn., 
1887, xxx, 47-56. 

Schumann. A Study of Hydrops Universalis Fetus. Trans. Am. Gyn. Soc., 
1915, xl, 12-32. 

Observations upon the Pathology and Treatment of Hydatidiform Mole. Trans. 
Am. Gyn. Soc., 1922, xlvii, 193-201. 

Schwab. De la syphilis du placenta. These de Paris, 1896. 

Schweitzer. Das pathologische Tiefenwachstum der Plazenta, etc. Archiv f. 
Gyn. 1918, cix, 618-668. 

Seitz. Die Luteinzellenwucherung in atretischen Follikeln. Zentralbl. f. Gyn., 
1905, xxix, 257-263. 

Ueber das primare Chorioepitheliom des Ovariums. Zeitschr. f. Geb. u. Gyn., 
1915, lxxviii, 244-259. 

Senge. Secundiire Carcinosis der Placenta bei priinarem Magencarcinom. Beit, 
z. path. Anat. u. z. allg. Path., 1912, liii, H. 3. 

Sfameni. Die Placenta marginata. Berlin, 1908. 

Shipley and Pearson. X-ray Pictures of the Bones in the Diagnosis of Syphilis 
in the Foetus and Young Infant. Bull. Johns Hopkins Hosp., 1921, xxxii, 
75-78. 

Simonart. Note sur les amputations spontanees. Archives de medecine Beige, 
1845, xviii, 112-119. 

Slemons. Placental Bacteremia. J. Am. Med. Assn., 1915, lxv, 1265-68. 

Stoeckel. Ueber die cystiche Degeneration der Ovarien bei Blasenmolen. Beitrage 
zur Geb. u. Gyn., Festschrifts dem Prof. Fritsch. Leipzig, 1902, 136-164. 

Strassmann. Oligo- und Polyhydramnie. Winckel’s Handbuch der Geb., 1904, 
i, 2 Halfte, 797-812. 

Sunde. Chorioepithelioma malignum. Acta Gyn. Scandinavica, 1921, i, 16-60. 

Teacher. On Chorionepithelioma, etc. Trans. London Obst. Soc., 1903, xiv, 
256-302. 

Tissier et Girauld. Syphilis congenitale. Bull. Soc. d’obst. de Paris, 1908, 
No. 1. 

Trinciiese. Bakteriologische u. histologische Untersuchungen bei kongenitaler 
Lues. Miinchener med. Wochenschr., 1910, lvii, 570-574. 

Ueber den Zeitpunkt der luetischen Infektioh des Foetus. Beitrage z. Geb. u. 
Gyn., 1913, xviii, 201-224. 

Vassmer. Zur ZEtiologie der Placentarcysten. Archiv f. Gyn., 1902, lxvi, 49-69. 

Veit. Ueber Deportation vom Chorionzotten. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 
466-504. 

Velpeau. Quoted by Virchow. 

Vineberg. Clinical Data on Chorioepithelioma, with End-results of Operative 
Treatment. Surg. Gyn. & Obst., 1919, xxviii, 123-137. 

Virchow. Myxom der Placenta. Die krankhaften Geschwiilste, 1863, i, 405-414. 

Myxoma fibrosum placentae. Die krankhaften Geschwiilste, 1863, i, 415. 

Volkmann. Ein Fall von interstitieller Molenbildung. Virchow’s Archiv, 1867, 
xli, 528-534. 

Wallart. Ueber die Ovarialveriinderungen bei Blasenmole, etc. Zeitschr. f. Geb. 
u. Gyn., 1904, liii, 36-75. 

Walz. Ueber Placentartumoren. Verh. d. deutschen path. Gesellschaft, 1907, x, 
279-282. 

Wegner. Ueber hereditare Knochensyphilis bei jungen Kincfern. Virchow’s 
Archiv, 1870, I, 305-323. 

Werth. Einseitiges Hydramnion mit Oligohydramnie der zweiten Trucht.. Archiv 
f. Gyn., 1882, xx, 353-377. 



700 


DISEASES AND ABNORMALITIES OF THE OVUM 


Williams. Deciduoma malignum. Johns Hopkins Hosp. Reports, 1895, iv, No. 9. 

The Frequency and Significance of Infarcts of the Placenta. Amer. Jour. Obst., 
1900, xli, 775-801. 

The Limitations and Possibilities of Prenatal Care. J. Am. Med. Assn., 1915, 
lxiv, 95-101. 

An Early Ovum in situ in the Act of Aborting. Am. J. Obst., 1919, lxxx, 269-283. 

The Significance of Syphilis in Prenatal Care and in the Causation of Foetal 
Death. Bull. Johns Hopkins Hosp., 1920, xxxi, 141-145. 

The Value of the Wassermann reaction in Obstetrics, Based upon the Study 
of 4,547 Consecutive Cases. Bull. Johns Hopkins Hosp., 1920, xxxi, 335-342. 

The Influence of the Treatment of Syphilitic Pregnant Women upon the 
Incidence of Congenital Syphilis. Bull. Johns Hopkins Hosp., 1922, xxxiii, 
383-386. 

Williamson. The Pathology and Symptoms of Hydatidiform Degeneration of 
the Chorion. Trans. London Obst. Soc., 1900, xli, 303-338. 

Wilson. Hydramnion in Cases of Uniovial or Homologous Twins. Trans. Lond. 
Obst. Soc., 1899, xli, 235-272. 

Wilton. Hydatids, terminating Fatally by Hemorrhage. Lancet, 1840, i, 691- 
693. 

Winckel. Teleangiektatisches Myxosarkom der Nabelschnur. Zentralbl. f. Gyn., 
1894, xviii, 397. 

Wlassow. Ueber die Patho- und Histo-genese des sogenannten Sarcoma angio- 
plastique. Virchow’s Archiv, 1902, clxix, 220. 

Woerz. Ein Fall von Hydramnios. Zentralbl. f. Gyn., 1895, xix, 580-581. 

Wolff. Ueber exp. Erzeugung von Hydramnion. Archiv f. Gyn., 1904, lxxi, 224- 
257. 

Fruchtwasser. Handbuch d. Bioehemie, 1910, iii, 709-741. 

Young. Aetiology of Eclampsia and Albuminuria. J. Obst. and Gyn. Brit. Emp., 
1914, xxvi, 1-29. 

Zilles. Studien fiber Erkrankungen der Placenta bedingt durch Syphilis. Tfi- 
bingen, 1885. 




CHAPTER XXIX 

ABORTION, MISCARRIAGE, AND PREMATURE LABOR 

Spontaneous expulsion of the ovum may occur at any period of preg¬ 
nancy, and is variously designated according to the degree of develop¬ 
ment which the product of conception has attained. Strictly speaking, 
one should distinguish between abortion, miscarriage, or premature labor, 
respectively, accordingly as the pregnancy terminates before the sixteenth 
week, between the sixteenth and twenty-eighth week, or at a later period. 

Prior to the sixteenth week, owing to the imperfect development of 
the placenta, the entire ovum often comes away intact. From that time 
on, however, the placenta forms a definite organ and the expulsion of 
an intact ovum is exceptional, the foetus, as a rule, being extruded first, 
and followed after a longer or shorter period by the placenta and mem¬ 
branes. After the twenty-eighth week the course of labor differs but 
little from that observed at full term, and the child, if properly cared 
for, may survive; its chances of so doing increasing in almost geo¬ 
metrical proportion with every additional week. 

As the term abortion is somewhat suggestive of a criminal procedure, 
it is rarely employed in popular parlance, all cases terminating prior 
to the period of viability being designated as miscarriages. Among 
medical men, on the other hand, the latter term is but little used, and 
it is customary to speak of all cases ending before the twenty-eighth week 
as abortions. 

Abortion: Frequency .—It is difficult to arrive at accurate conclusions 
concerning the frequency with which spontaneous abortion occurs. Re¬ 
liable vital statistics are not yet available in America, and, inasmuch 
as only women who are more or less seriously ill following abortions 
enter hospitals for treatment, the statistics based upon their records 
would give too low an estimate—-in my service about 6 per cent, of all 
patients. On the other hand, sufficiently large series from private prac¬ 
tice are not available; though Malins found that 19.23 per cent, of the 
pregnancies of 2,000 patients ended in abortion. A conservative estimate 
would indicate that about every fifth or sixth pregnancy in private prac¬ 
tice ends in spontaneous abortion, and the percentage would be increased 
considerably were the very early cases taken into account, in which a pro¬ 
fuse loss of blood follows the retardation of the menstrual period for a 
few weeks. Taussig estimates that one abortion occurs to every 2.3 
labors, and considers that considerably over one quarter are criminally 
induced. It is difficult to give accurate figures concerning the fre¬ 
quency of the latter, but it is generally admitted that the induction of 
criminal abortion is practiced with increasing frequency in all strata of 

701 









702 


ABORTION, MISCARRIAGE, AND PREMATURE LABOR 


society. Following the World War the increase has become alarming, 
and Schottelius states that official figures indicate that in Hamburg dur¬ 
ing the year 1919, 52 per cent, as many abortions occurred as full term 
deliveries. 

Etiology.—In the early months of pregnancy spontaneous expulsion 
of the ovum is nearly always preceded by the death of the foetus. For 
this reason, the consideration of the etiology of early abortion prac¬ 
tically resolves itself into determining the cause of foetal death. In the 
later months, on the other hand, the foetus is frequently born alive, and 
other factors must be invoked to explain its expulsion. Foetal death 
may be due to abnormalities occurring in the ovum itself, to abnormali¬ 
ties of the generative tract, or to systemic disease on the part of the 
mother, and now and again of the father. 

(a) One of the most usual causes for the death of the foetus is to be 
found in abnormalities of development, which are inconsistent with life. 
The investigations of Mall indicate that such conditions are present in 
one-third of all early abortions, and would have resulted in monstrosities 
had pregnancy continued. We are as yet completely ignorant concerning 
the causation of such abnormalities in human beings, but reasoning from 
the results obtained in experimental teratology, it would seem probable 
that two main sets of factors are concerned :—abnormalities in the earliest 
stages of segmentation of the ovum, and changes in its environment. 
Stockard and others have shown that temporary reduction in the supply 
of oxygen or radical changes in temperature may lead to the death of 
the ovum or to such retardation of growth as to lead to the production 
of monstrosities. At a somewhat later period foetal death may result 
from changes in the appendages of the ovum, such as excessive torsion 
of the cord, hydramnios or hydatiform mole. In the last-named affec¬ 
tion the nutritive material conveyed to the intervillous spaces by the 
maternal blood merely suffices to nourish the hypertrophic villi, little or 
none remaining to be transmitted to the child. 

Figure 510 is a diagrammatic reconstruction of an early ovum in the 
act of aborting. The specimen was discovered accidentally in a uterus 
removed 38 days after the onset of the last menstrual period. Although 
no symptoms of impending abortion were observed, it was clearly in¬ 
evitable, as one pole of the ovum was emerging through the ruptured 
decidua capsularis. The process must be regarded as conservative, as 
the ovum was hopelessly abnormal, no trace of an embryo being discover¬ 
able in the celomic cavity, while some of the villi nresented the changes 
characteristic of hydatiform mole. 

Still later in pregnancy, certain diseases and abnormalities of the 
placenta may lead to the same result. Thus, Merttens and Franque have 
described an obliterating endarteritis in the vessels of the chorionic villi, 
independent of syphilis, which interferes with the foetal circulation to 
such an extent as to be incompatible with life. In other cases, the 
abundant formation of red or white infarcts may throw so large a portion 
of the placenta out of function that the remainder is not sufficient to 
supply the needs of the foetus. Furthermore, such abnormalities as pla¬ 
centa previa, low implantation of the placenta, or velamentous insertion 




ETIOLOGY 


703 


of the cord, as well as premature separation of the placenta, may like¬ 
wise bring about circulatory conditions inconsistent with foetal life. 

Syphilis is usually mentioned as one of the most frequent factors 
concerned in the production of abortion. In my experience, it plays 
but little part during the first half of pregnancy, but, on the other hand, 
it constitutes the most important single factor in the etiology of prema¬ 
ture labor. Support is lent to this view by the fact that no one as yet 
has been able to demonstrate the presence of spirochetes in the tissues of 
foetuses expelled by syphilitic mothers during the first half of pregnancy, 
but all observers agree that they can be found with increasing frequency 
in each successive month of the second half. 

Diseases of the maternal kidneys, heart, liver and lungs are rarely 
concerned in producing abortion, but, as will be indicated in a later sec¬ 
tion, they play a prominent part in the causation of premature labor. 

( b ) As was pointed out in the chapter upon the Accidental Com- 


D-C- 



Fig. 510.—Diagram Showing an Ovum in the Act of Aborting, 38 Days from Onset 
of Last Menstrual Period. The Free Pole is Emerging through the Rup¬ 
tured Decidua Capsularis, while the Other Pole is Still in Connection with 
the Decidua. D. C ., Decidua Capsularis. D. V ., Decidua Vera. 

plications of Pregnancy, all acute infectious diseases have a tendency to 
bring about the death of the child and its subsequent expulsion from 
the uterus. The fatal result is usually due to the transmission of toxins, 
and occasionally of the specific microorganisms from the mother to the 
child. Poisoning with phosphorus, lead, illuminating gas, and other 
substances may lead to similar results. 

Foetal death is sometimes attributable to malnutrition on the part of 
the mother, although this is very exceptional. On the other hand, it is 
not unusual for women suffering from wasting diseases to give birth to 
fully developed children. 

(c) Generally speaking, abnormalities in the generative tract play 
a most important part in the etiology of abortion. Thus, developmental 
anomalies of the uterus, or imperfect development of the normally 
formed organ, may be responsible for conditions which are unfavorable 
for the implantation of the ovum and later for the development of the 
placental circulation. Chronic metritis is supposed to act in the same 
way. Dense adhesions about the tubes and ovaries, resulting from in- 













704 


ABORTION, MISCARRIAGE, AND PREMATURE LABOR 


flammatory processes, only rarely interfere with the expansion of the 
uterus sufficiently to give rise to abortion, since in most cases the bands 
of adhesions gradually stretch and become elongated. 

Displacements of the uterus, more particularly retroflexion and pro¬ 
lapse, are justly considered as very important factors in the causation of 
abortion. As a rule, the interruption of pregnancy is due less to the 
abnormal position of the uterus than to lesions of its lining membrane 
resulting from circulatory changes incident to it. In the rare cases of 
incarceration, however, the accident must he attributed to pressure ex¬ 
erted by the surrounding parts upon the abnormally placed organ. 

The most important condition of the generative tract leading to the 
production of abortion is afforded by diseases and abnormalities of the 
decidua. In the hypertrophic form of decidual endometritis—decidua 
polyposa—the bulk of the maternal blood brought to the uterus goes to 
nourish the hyperplastic decidua, while in the atrophic forms the con¬ 
ditions are unfavorable for the implantation of the ovum and the de¬ 
velopment of the placenta. More important still is the part played by 
chronic glandular hyperplasia and acute inflammation of the decidua. 
These lesions are frequently accompanied by hemorrhagic changes, and, 
excepting the ill-defined conditions which are responsible for defective 
development of the foetus, are the most frequent causes of abortion in 
the early months. Histological examination demonstrated the presence 
of acute or chronic decidual endometritis in 70 per cent, of my speci¬ 
mens, hut in many instances it was impossible to determine whether it 
was the primary cause, or merely an accidental complication. The occur¬ 
rence of abortion associated with the presence of myomata in the walls of 
the uterus must he attributed less to the mechanical effect of the tumor 
itself than to changes in the decidua incident to it. 

(d) In a few cases the cause of abortion is to be sought for in reflex 
influences, which take their origin from lesions of the generative tract 
or from irritative conditions about the breasts. In verv rare instances 

v' 

the accident is attributed to intense mental emotions—anger, fright, or 
grief. 

It is customary to distinguish between predisposing and exciting 
causes of abortion. The various factors to which allusion has just been 
made predispose to abortion, while the exciting cause is often of a 
mechanical nature, such as a slight fall, jar, or overexertion. The state¬ 
ments of the patient concerning the latter, however, must be received 
with caution, as in many cases they are merely incidental and have no 
connection with the actual cause. At the same time, it must be admitted 
that the apparently healthy uterus sometimes possesses an abnormal 
degree of irritability, and will react to stimuli which ordinarily would 
be without effect. In such women the slightest violence, such as c oitus. 
a simple bimanual examination, a misstep, tripping over a carpet, or a 
ride over a rough road, may bring on an abortion; while in others the 
most violent exercise and the rudest manipulations may be borne with 
impunity. For example, every physician can recall cases in which a sound 
has been introduced into the pregnant uterus without ill effects, and it 
is well known that, in the later months, the repeated introduction of a 



ETIOLOGY 


705 


large bougie, or even of a Champetier de Kibes balloon, may fail to bring 
about satisfactory uterine contractions. 

(e) Formerly, syphilis was mentioned as the chief paternal cause 
of abortion. As has already been indicated, this disease plays little or 
no part in the interruption of pregnancy during its first half. On the 
other hand, evidence is accumulating that excessive and long continued 
use of alcohol, lead intoxication, and other forms of chronic poisoning 
may so affect the vitality of the spermatozoa that, although the process 
of fertilization may proceed normally, the product of conception is 
incapable of continued normal development. 

It is not unusual to meet with women who give a history of repeated 
abortion occurring at about the same time in a number of successive 
pregnancies. In many such cases careful examination will demonstrate 
the existence of an endometritis or a uterine displacement; and it is 
only after the cure of the underlying condition that subsequent preg¬ 
nancies can be expected to progress to full term. In other instances 
no such lesions exist, nor will the most extended clinical study give a 
clue to the cause, and consequently the treatment of such patients is 
empirical and altogether unscientific. At present there is a tendency to 
regard repeated abortion as a manifestation of abnormal function of 
certain of the ductless glands, but as yet satisfactory evidence has not 
been adduced in support of such a view. 

The experimental work of Reynolds and Macomber upon the effect 
of dietary factors in the causation of sterility, as well as the experience 
of animal breeders, suggests the possibility that the prolonged use of 
defective diet, while not interfering with fertility, may so affect that 
vitality of the germ cells that the product of conception will be able to 
attain only a certain stage of development before succumbing. With this 
idea in mind, it might be well in suitable cases to make inquiries con¬ 
cerning the dietetic habits of the patient and her husband. 

After Bang, McFadyen, Theobald Smith and others had directed 
attention to the epidemic form of abortion which occurs in cattle, and 
had shown that it is due to one of several specific microorganisms—the 
bacillus abortus of Bang and the vibrio foetus of Smith—and that healthy 
animals can be infected by their inoculation into the generative tract, 
it was suggested that repeated abortions in women might be susceptible 
of a similar explanation. Such a view was soon abandoned for two 
reasons: First, that there is no similarity between the conditions in 
cows and women; for in the former the infection almost invariably leads 
to permanent sterility, to which is due the great economic loss associated 
with the disease; while in women the possibility of conception is in no 
way affected, but each succeeding pregnancy ends in abortion at about 
the same period as its predecessor. In the second place, there is no evi¬ 
dence of the infectious nature of repeated abortions in women, nor of 
the transfer of the disease from one individual to another. Further¬ 
more, bacteriological examination has failed to reveal the presence of 
analogous microoorganisms, and while bacteria are frequently found in 
the uterus of such patients they are simply the well known pyogenic or 
putrefactive varieties. Complement-fixation tests carried out by Wil- 







706 ABORTION, MISCARRIAGE, AND PREMATURE LABOR 

liams and Kolmer. have likewise failed to show that the bacillus abortus 
plays any part in the causation of abortion in women. 

Those interested in further details concerning infectious abortion in 
cattle are referred to the several publications of Theobald ►Smith, and to 
W. L. Williams* text-book upon veterinary obstetrics. 

Pathology.—In spontaneous abortion, the immediate cause of the 
expulsion of the ovum is to be found in hemorrhagic changes in the 
decidua. Concerning their mode of production we must confess a pro¬ 
found ignorance, except when endometritis is 
the underlying cause. These changes, which are 
most marked in the decidua basalis, are fol¬ 
lowed by degeneration of the affected tissues, as 
the result of which the attachment of the ovum 
becomes more or less loosened, and the product 
of conception comes to act as a foreign body, and 
in turn gives rise to uterine contractions, which, 
after a longer or shorter period, finally lead to 
its expulsion. 

Especially in the early months, the entire 
ovum may be expelled after a few premonitory 
symptoms, and frequently the entire decidual 
lining of the uterine cavity is cast off with it. 
In such cases a triangular sac comes away which 
represents the decidua vera, which contains in 
its interior the vesicular ovum, covered by the 
decidua capsularis. More frequently, however, 
the decidua vera remains in utero, while the 
ovum, surrounded by the decidua capsularis, is 
expelled. Occasionally the latter is torn through, 
and, together with the decidua vera and basalis, 
is retained in utero, while a shaggy, more or less 
spherical structure is cast off—the ovum sur¬ 
rounded by the chorionic villi. As pregnancy advances, the expulsion 
of the entire ovum is observed less frequently, so that after the fourth 
month it is the rule for the membranes to rupture and the foetus to be 
expelled by itself, to be followed spontaneously, or not, by the placenta 
and membranes. 

In many early abortions, the expelled ovum is a thin-walled cystic 
structure, filled with clear fluid and containing a minute degenerated 
embryo, or only a remnant of the umbilical cord. This condition rep¬ 
resents an early stage of hydramnios, and corresponds to the dropsical 
or blighted ovum of the early writers. 

In many instances, the process of abortion occurs very slowly, so 
that the blood poured out between the periphery of the ovum and the 
decidua has an opportunity to coagulate. Under such conditions, the 
ovum on its expulsion is surrounded by a capsule of clotted blood of 
varying thickness with degenerated chorionic villi scattered through it. 
n its interior is a small cavity filled with clear fluid and lined by a thin, 
glistening membrane (the amnion), from one point of which hangs the 



Fig. 511. —Early Abor¬ 
tion, Showing De¬ 
cidua Reflexa and 
Serotina with De¬ 
generate Embryo. 
X 1. 







ETIOLOGY 


707 


umbilical cord and the degenerated foetus. Such structures are classified 

! as blood 01 cat neous moles, according to their appearance. In the former 
the capsule of coagulated blood is red in color, while in the latter it pre¬ 
sents a paler appearance, the result of fibrin formation (Eig. 512). 

Now and then, the interior of such 
structures, instead of being lined by 
the smooth amnion, may present an 
irregular nodular appearance, which is 
due to the formation of hematomata 
of varying size beneath the amnion and 
chorionic membrane. This condition, 
to which Granville applied the term 
ovum tuberculosum , has been more par¬ 
ticularly studied by Breus who desig¬ 
nated it as tuberous subchorial hema¬ 
toma of the decidua (Fig. 513) ; while 
Berry Hart, and Taussig described the 
condition as hematoma mole, or tub¬ 
erous fleshy mole, respectively. Breus 
believed that the tuberous appearance 
was the result of hemorrhage* into col¬ 
lapsed folds of the amnion, while 
Gottschalk, Walther, Hart, and others 
considered that the hemorrhage was 
the primary factor. Davidsohn and 
Taussig take the view that the disproportion between the size of the 
foetus and the ovum is the result of hydramnios, and after the death of 
the former the amniotic fluid is gradually absorbed, when the redundant 
amnion is thrown into folds, the blood being effused into their in¬ 
terior. 

In all uterine moles the foetus is either lacking or is relatively smaller 
in size than would naturally correspond with the menstrual history. This 
fact indicates that the process is of gradual formation, and that a con¬ 
siderable period has elapsed between the death of the foetus and the 
expulsion of the ovum. Not uncommonly, indeed, the foetus may 
undergo complete dissolution, or be represented merely by a stub of 
umbilical cord hanging from the interior of the ovum. In the former 
event, after resorption of the amniotic fluid, the ovum may be represented 
by a solid mass of varying size, composed of the collapsed amniotic cavity 
and of chorionic villi embedded in coagulated blood. 

Dissolution of the dead foetus is possible only in the early weeks of 
pregnancy, and cannot occur after it has attained any considerable pro¬ 
portions. In the latter class of cases the retained foetus may undergo 
maceration. In such circumstances, the bones of the skull collapse, the 
abdomen becomes distended with a blood-stained fluid, and the entire 
foetus takes on a dull reddish color due to staining with blood pigment. 
At the same time the skin softens and peels off at the slightest touch, 
leaving behind the bright-red corium. The internal organs degenerate, 
and become soft and friable, losing their capacity for taking up the usual 



Fig. 512.—Section through Bi.ood 
Mole. X 1. 






708 ABORTION, MISCARRIAGE, AND PREMATURE LABOR 

histological stains. In rarer instances the foetus becomes compressed an 
takes on a dry, parchmentlike appearance, known as mummification. 

Although this condition is rarely observed in ordinary abortion, i 
is noted with comparative frequency in twin pregnancies, when on 
foetus has died at an early period while the other has gone on to fu 
development—foetus papyraceus. 

In very exceptional instances, the foetus may he retained in uten 
for a long period, until the deposition of lime salts upon it converts 
into what is known as a lithopedion. This phenomenon, though e? 



tremely rare in uterine pregnancy in human beings, is relatively common 
in the lower animals. In extra-uterine gestation, on the other hand, it 
is not of unusual occurrence. 

Clinical History.—The onset of abortion is usually preceded by cer¬ 
tain premonitory symptoms, the most important of which are hemor- 
rhage and pain in the back and lower abdomen. Loss of blood, no matter 
how slight, in the early months of pregnancy, should always be regarded 
v/ith suspicion, for, if it be not a premonitory symptom of abortion, it 
usually indicates the existence of a decidual endometritis, or an abnormal 
implantation of the placenta. hen due to the former, the discharge 











CLINICAL HISTORY 


709 


is usually not very profuse, and is of a dirty brown or brownish-red 
color, while when due to the latter it is apt to be more profuse and dis¬ 
tinctly bloody in character. The premonitory bleeding may persist for 
weeks, or be promptly followed by the expulsion of the ovum. Indeed, 
in some cases the latter event may occur so rapidly as to surprise the 
patient. 

When a patient in the first months of pregnancy begins to lose 
blood, and the flow is associated with pain in the lower abdomen and 
back, an abortion is threatened. It, however, does not become imminent 
unless the hemorrhage be profuse or the cervix considerably dilated; even 
in the latter event it is not impossible for the disturbance to subside, 
and for pregnancy to go on without interruption. On the other hand, 
rupture of the membranes and escape of the liquor amnii indicate that 
abortion is inevitable. 

When abortion becomes imminent, the hemorrhage is usually quite 
profuse, though as a rule not sufficient to endanger the life of the 
woman. At the same time she experiences severe cramplike pains in the 
abdomen due to the uterine contractions, which later become distinctly 
bearing-down in character. After the cervix has become sufficiently 
dilated, the detached ovum may be expelled intact from the uterus, and 
when not retained in the vagina comes away spontaneously. This is 
known as complete abortion. 

More frequently, on the other hand, after rupture of the membranes 
and the escape of the amniotic fluid, the foetus alone is expelled, while 
the placenta and membranes remain in the uterus —incomplete abortion. 
In such cases the hemorrhage usually persists until the retained struc¬ 
tures are extruded spontaneously or are removed artificially, though the 
pains usually cease with the expulsion of the foetus. After the uterus 
has rid itself of the product of conception, the hemorrhage and pain 
cease, and a process of involution begins, identical with that observed 
after full-term labor. In my experience spontaneous complete abortion 
occurs most frequently during the first three months of pregnancy. In 
197 spontaneous abortions occurring in my service and analyzed by 
Titus, the relative incidence of the complete to the incomplete variety 
was in the ratio of one to five. Such figures, however, understate the 
frequency of complete abortions, as a large proportion of the patients 
entered the hospital only because of profuse and prolonged hemorrhage 
incident to the incomplete extrusion of the foetal membranes, so that 
I estimate that a ratio of one to three would be more in accordance 
with the actual facts. 

Treatment.—Prophylactic treatment is most important, although, as 
a rule, it is not available in women aborting for the first time. After the 
patient has recovered from the abortion, a careful local and general 
physical examination should be made, and, in case any abnormality is 
discovered, the necessary curative or precautionary measures should be 
instituted before renewed conception occurs. If the uterus is retro- 
flexed, the organ should be replaced and held in position by a properly 
fitting pessary. If the desired results are not obtained in this way, the 
uterus should be suspended by a suitable operation. If endometritis 




710 


ABORTION, MISCARRIAGE, AND PREMATURE LABOR 


be present, curettage should be done, and the patient warned against 
becoming pregnant until sufficient time has elapsed to allow the uterus 
to recover from the morbid condition. 

If past experience has shown that the uterus is irritable and that 
the patient is predisposed to abort upon the slightest provocation, coitus 
should be interdicted during pregnancy, and the patient be cautioned 
against over-exertion, particularly upon the days during which the 
menstrual period would ordinarily occur, and be encouraged to lead a 
careful, well-ordered existence. Occasionally, the only means of leading 
the process to a successful termination is by keeping the patient in bed 
throughout pregnancy. 

Treatment of Threatened Abortion .—Whenever symptoms of threat¬ 
ened abortion appear, the patient should be kept in a recumbent position 
in bed. If pains occur, a hypodermic injection of *4 grain of morphin 
should be administered at once, to be followed by 1-grain rectal supposi¬ 
tories of extract of opium, repeated at intervals of four or six hours. Bet¬ 
ter results are sometimes obtained by combining the opium with the 
extract of hyoscyamus. The following suppository, administered every 
four or six hours, according to circumstances, often serves a useful 
purpose: 


W Codiae sulphat. gr. ss. 

Ext. hyoscyami. gr. j. 

01. theobromae. q. s. 


In many instances the symptoms rapidly subside under such treat¬ 
ment, but the patient should be kept in bed for some days after their 
disappearance, in the hope of avoiding any repetition. Unless the loss 
of blood is excessive it is unwise to subject the patient to a thorough 
pelvic examination during the first few days for fear that the manipula¬ 
tion may convert a threatened into an inevitable abortion. On the other 
hand, exploration should not be too long deferred, as in many cases 
similar symptoms are associated with extra-uterine pregnancy, and the 
failure to recognize the tubal swelling may result in postponing operative 
interference until after rupture has taken place into the peritoneal cavity. 

In other cases, the pain yields to the administration of sedatives, but 
the hemorrhage persists, and we then have to decide how long we are 
justified in permitting the bloody uterine discharge to continue, and 
whether there is any probability that the pregnancy will progress 
normally. 

So long as the loss of blood does not exceed that usually observed at 
the menstrual period, the flow is not necessarily incompatible with the 
continuance of pregnancy, and may be permitted to go on for some 
time. In view of the part played by developmental abnormalities of the 
foetus in the production of abortion, it is apparent that in many in¬ 
stances its occurrence should not be regarded as a misfortune, but rather 
as a conservative effort on the part of Nature to rid the organism of a 
product of conception which cannot attain maturity. For this reason I 
am of the opinion that palliative treatment is frequently continued un¬ 
necessarily long. Consequently, if the symptoms do not disappear 






TREATMENT 


711 


within ten days or two weeks, the patient should be allowed to assume 
her usual avocations, in the hope that the threatened abortion will be¬ 
come inevitable. On the other hand, if the bleeding at any time be¬ 
comes so profuse that the patient begins to show signs of anemia, the 
uterus should be at once emptied by the methods to be described below. 
In occasional instances, notwithstanding appropriate treatment and rest 
in bed, slight hemorrhage may persist for weeks, and it then becomes 
necessary to ascertain whether there is any possibility of the pregnancy 
continuing. Unfortunately, this problem cannot be solved at once, but 
necessitates a delay of several weeks and repeated bimanual examinations. 
Thus, if at the end of two or three weeks one is convinced that the 
uterus has not increased in size, or has even become smaller, one is 
justified in concluding that the foetus has perished; while, on the other 
hand, an increase probably indicates that it is still alive, but does not 
necessarily mean that pregnancy will go on to a happy termination. As 
soon as we are convinced that the foetus is dead, the uterus should be 
emptied. In such cases nothing can be gained by delay, as abortion 
will inevitably occur sooner or later, whereas temporizing treatments 
entails a waste of time and sometimes exposes the patient to serious 
danger. 

Treatment of Inevitable Abortion .—When convinced that abortion is 
inevitable, particularly in those cases in which the hemorrhage is pro¬ 
fuse, the uterus should be emptied in the most conservative manner, the 
choice of procedure depending upon the consistency and the degree of 
dilatation of the cervix. If it be sufficiently patulous to admit a finger, 
the patient should he anesthetized, brought to the edge of the bed, and 
prepared for operation. After preliminary dilatation of the outlet, the 
carefully sterilized hand, anointed with sterile albolene or green soap 
| solution, is introduced into the vagina, and one or preferably two 
fingers are carried up into the uterine cavity, and, under the guidance 
of the other hand applied over the abdomen, peel off the ovum from 
the uterine wall and slowly extract it. If this cannot be effected, the 
ovum should be broken up by the finger, and its fragments extracted 
by means of a placental or ovum forceps, under the guidance of a finger 
within the uterus. 

But if, as often happens, the cervix is not sufficiently dilated to per¬ 
mit the introduction of a finger, the cervical canal and vagina should be 
packed tightly with a narrow sterile gauze bandage, as described in 
Chapter XXIV. When removed at the end of twenty-four hours, the 
pack frequently brings with it the intact ovum; but, even if this does 
not occur, the cervix will generally be sufficiently dilated to permit the 
introduction of the finger, when the ovum can he removed as recom¬ 
mended above. Dilatation of the cervix by means of a laminaria tent 
is recommended by many authorities. While it effects that puipose \ei\ 
satisfactorily, I strongly deprecate its employment, as I know no way hy 

which it may be rendered absolutely sterile. 

Except when the hemorrhage is so profuse as seriously to threaten 
the patient’s life, these methods of procedure are preferable to the rapid 
dilatation of the cervix with a Goodell or some similar dilator, followed 



712 


ABORTION, MISCARRIAGE, AND PREMATURE LABOR 


by the immediate removal of the ovum by means of a curette or polypus 
forceps. Moreover, if the cervix is resistant it is frequently impossible 
to dilate it sufficiently by such means to permit the introduction of 
the finger, the employment of which, in my opinion, is essential for 
the proper evacuation of the uterus and the careful exploration of its 
cavity after the removal of the ovum. 

No doubt the uterus can be satisfactorily evacuated in most cases by 
means of the curette and polypus forceps, but no instrument has ever 
been invented which will prove an efficient substitute for the carefully 
trained sense of touch when it becomes necessary to satisfy one’s self 
that no remnants of the ovum are still retained in the uterus. On 
several occasions I have seen patients profoundly exsanguinated from 
profuse hemorrhage following the supposed thorough removal of the 
product of conception by curettage, but, on introducing the finger into 
the uterus, I have found that it still contained the bulk of the ovum. 
Experiences of this kind have therefore led me to do away with the use 
of instruments except in very rare cases. Moreover, in addition to the 
fact that they fulfill their object only imperfectly, they are not devoid 
of danger. Every gynecologist is familiar with cases in which the 
softened uterus has been perforated by the curette, and knows of 
instances in which a loop of gut has prolapsed through the opening so 
made. With these experiences in mind, it has become more and more 
my practice to resort to vaginal hysterotomy whenever prompt evacuation 
of the uterus becomes necessary in the presence of a rigid cervix, the only 
contra-indication being the existence of infection. 

When the ovum has been expelled intact, as in complete abortion, 
there is no necessity for further interference; and, as a rule, if the 
decidua vera is not cast off, it is not advisable to attempt its removal, 
as it is usually expelled spontaneously within a few days. At the same 
time, the physician should always satisfy himself by careful inspection 
that the entire ovum has come away, and that portions of it are not 
retained. For this reason, those in attendance on the patient should be 
instructed to preserve anything that may be passed in the absence of 
the physician, and not to follow the almost universal tendency to dis¬ 
pose of it at once; as careful inspection by a trained observer is required 
to recognize the component parts of the expelled ovum. 

In incomplete abortion, on the other hand, the retained placenta and 
membranes should be removed manually by the methods already de¬ 
scribed, since as soon as the uterus is emptied it contracts and the 
danger of hemorrhage has passed. In such cases it may happen that 
the physician does not see the patient until some days after the ex¬ 
pulsion of the foetus, when he is summoned on account of the persistent 
loss of blood, and upon examination finds that the cervix has become 
retracted to such a degree that it will not admit the finger. In this 
event, it can readily be sufficiently dilated by means of a Goodell dilator 
to permit the introduction of a finger, after which the remnants of the 
ovum are removed. 

In many cases of criminally induced abortion, or in neglected cases, 
infection may occur. Symptoms may develop while the entire ovum is 






MISSED ABORTION 


713 


still in the uterus, during the course of an incomplete abortion, or 
after the completion of the entire process. The latter will be con¬ 
sidered in the chapter upon Puerperal Infection. The two former con¬ 
ditions are always serious, and are responsible for the greater part of the 
deaths following abortion. The infection may be due to the ordinary 
pyogenic bacteria or to the various so-called putrefactive types, and in 
hospital practice it is advisable to take an intra-uterine culture before 
undertaking any manipulation. The prognosis is always serious when 
the former bacteria are concerned, hut is favorable when they are absent. 
In either event, the uterus should he promptly emptied in the most con¬ 
servative manner, and afterward washed out with sterile salt solution. 

The complication of a rigid cervix is always a source of anxiety, 
for, if the ovum is still in utero, the existence of infection contra¬ 
indicates the employment of vaginal hysterotomy, and renders more 
serious the lacerations which are usually associated with instrumental 
dilatation. On the other hand, in cases of infected incomplete abor¬ 
tion the uterus can usually be emptied without difficulty. Fortunately, 
in the great majority of cases, the temperature promptly falls after 
evacuating the uterus, and the patient goes on to complete recovery. 
In my streptococcus cases, however, the mortality was high, and, in 
view of a similar experience, Winter in 1911 raised the question 
as to whether it would not be better to defer interference until 
the acute symptoms have subsided. That the question is still sub judice 
is shown by the fact that Halban, and Latzo ten years later, after an 
experience in thousands of cases hold diametrically opposing views, the 
former advocating and the latter deprecating active interference. In 
general, it may be said that it is safer to interfere when the infection is 
limited to the uterus; whereas, if it has spread beyond it, as is indicated 
by pain on palpation, it is wiser to wait until the acute symptoms have 
subsided. 

With the exception of infected cases, the prognosis following abor¬ 
tion is excellent, provided a rigid technic is scrupulously observed. I 
have never had a death in an uninfected patient, and Young and 
Williams in a series of 1,331 cases, with an operative incidence of 87 
per cent., record a mortality of only 0.07 per cent. 

The treatment of repeated abortion is in general so unsatisfactory as 
to constitute one of the opprobia of obstetrics. Unless some definite 
cause can be discovered and corrected by appropriate treatment, prac¬ 
tically our only resource is to keep the patient in bed until the time of 
danger is well past. Blair Bell claims that he has obtained good results 
by the administration of corpus luteum extract, but in my experience it 
has not been efficient. 

Missed Abortion.—This term was applied by Oldham to the cases in 
which the foetus is retained in the uterine cavity for months or years 
after its death. The condition occurs frequenly in mares, cows, and 
sheep, but comparatively rarely in women. Seventy cases were collected 
from the literature by Graefe in 1896, and 105 by E. Fraenkel in 1903, 
though I am convinced from my own experience that such figures give a 
very inadequate idea of its incidence. 






714 ABORTION, MISCARRIAGE, AND PREMATURE LABOR 


Retention may exist for a long period without giving rise to symp¬ 
toms, and such a possibility should always be borne in mind in the case 
of an abortion occurring in a woman who has been for some time sepa¬ 
rated from her husband, inasmuch as an error in this regard occasionally 
results in irreparable damage to her character. In other cases the patient 
may believe herself to be far advanced in pregnancy, and yet on exami¬ 
nation the size of the uterus will be found to correspond to that of a 
much less advanced period. More frequently, however, the patient may 
present signs of threatened abortion, but, after a varying period, the 
loss of blood and the pain disappear under appropriate treatment, so 
that there seems to be every prospect that the pregnancy will go to 
term. Some months later the physician will be consulted on account 
of the failure of the abdomen to enlarge, or because the breasts show 
regressive changes, when the uterus will be found to be smaller than 
it was at the time of the threatened abortion. In rare instances, when i 
foetal death has occurred very early in pregnancy, the enlargement of 
the uterus may be so slight as to escape recognition, and the condition 
may be regarded as one of essential amenorrhea. This happened in 
one of my patients, in whom the true state of affairs was not recognized 
until the small product of conception w r as expelled thirteen months after 
the last menstrual period. Not uncommonly the condition, after per-1 
sisting for months without symptoms, may exert an appreciable effect 
upon the patient, who may suddenly begin to lose flesh, suffer from a 
foul taste in her mouth, perhaps present a slight elevation of tempera¬ 
ture, and occasionally symptoms of mental derangement. 

According to Veit and Graefe, the retention is to be attributed to a 
lack of irritability on the part of the uterus, -which does not contract i 
as usual under the stimulation exerted by the dead ovum acting as a 
foreign body. In quite a number of cases the foetus has been retained j 
for more than one year, and in one instance for twenty-eight years. I 
After expulsion the ovum frequently presents the characteristic struc¬ 
ture of a hematoma mole; in other cases there are no manifestations of 
hemorrhage, and one has to deal with a so-called “dropsical ovum.” In 
the case to which reference v r as made in the preceding paragraph, the ] 
ovum v'as represented by an almond-shaped mass, covered by decidua] I 
tissue, and containing in its interior closely packed chorionic villi v T itb • 
v'ell-preserved epithelium, but without a trace of a foetus or amniotic 
cavity. 

Whenever the diagnosis is established beyond doubt, the cervix should 
be dilated or incised, and the uterus emptied of its contents. In several! 
of my cases, the cervix was so firm, that vaginal hysterotomy seemed ; 
the most conservative method of overcoming its resistance. 

In very exceptional instances the entire product of conception may be 
absorbed without a sign of external discharge. Polano and L. Fraenkel, 
have reported cases in which this occurred after the pregnancy had | 
advanced as far as the fourth month, and Koebner has demonstrated iff 
possibility by animal experiments. 

Premature Labor.—By this is understood the spontaneous termina- j 
tion of pregnancy after the period of viability has been reached—twenty- 1 






PREMATURE LABOR 


715 


eighth week—but before the child has attained maturity. For statistical 
purposes it is customary to designate as premature children which weigh 
between 1,500 and 2,500 grams or measure between 35 and 45 cm. 
in length. 

The accident may be due to one of numerous factors, the most im¬ 
portant being syphilis and continuous overwork during the later months 
of pregnancy. Less frequently, abnormalities of the product of con¬ 
ception, the various toxemias and chronic Bright's disease, lesions of the 
heart and lungs, as well as certain operations upon the generative tract, 
may be etiological factors. As is well known, marked degrees of hydram- 
nios are frequently associated with premature labor, which is usually 
attributed to the excessive distention of the uterus. Placenta previa also 
plays an important part, and it is generally recognized that the high 
foetal mortality associated with the condition is attributable to the 
fact that it frequently leads to the premature termination of pregnancy. 
Abnormalities in the development of the foetus, and more particularly the 
grosser forms of monstrosity, also lead to a similar result, but we are 
as yet unacquainted with the mechanism by which such conditions give 
rise to premature expulsive efforts. The various types of toxemia, 
particularly eclampsia and nephritic toxemia, frequently lead to pre¬ 
mature labor. In the former, it is well known that the onset of con¬ 
vulsions is soon followed by uterine contractions, so that it is frequently 
difficult to determine whether one has to deal with ante- or intrapartum 
eclampsia. Nephritic toxemia often leads to the premature expulsion 
of a poorly nourished child or one which is already dead. Such a 
result may be due to the underlying maternal toxemia or to infarct 
formation in the placenta, which is sometimes so extensive as to inter¬ 
fere seriously with its nutritive function. 

Many authors ascribe considerable etiological significance to valvular 
lesions of the heart, and believe that the death of the child and the 
premature uterine contractions are attributable to deficient oxygena¬ 
tion of the foetal and maternal blood. From my experience, however, 
the importance of such lesions, as well as those of the lungs, appears to 
be exaggerated. 

One of the most important causes of premature labor consists in 
certain operations which had been previously performed upon the cer¬ 
vix—the extensive repair of old lacerations and particularly high ampu¬ 
tation. Each year I see several patients who had previously had one 
or more normal labors, but who, following such an operation, are unable 
to carry subsequent pregnancies to term. In such patients, gestation 
proceeds uneventfully until the sixth or seventh month when premature 
labor sets in without apparent cause. In my experience prophylactic 
treatment is of no avail, as absolute rest in bed for months befoie 
the danger period fails to avert the accident, so that the woman seems 
doomed to repeated premature labor as long as the reproductive function 
persists. For this reason I consider that high amputation of the cervix 
is an extremely serious procedure from an obstetrical point of view, and 
consequently should be restricted to women who have already passed 
the menopause, except under the most pressing indications. 





716 ABORTION, MISCARRIAGE, AND PREMATURE LABOR 


In the absence of any of the conditions enumerated, the birth of a 
living premature child may be regarded as an accidental occurrence, 
but the expulsion of a macerated child should arouse the strongest suspi¬ 
cion of syphilis, which should not be dismissed unless autopsy upon 
the child, microscopic examination of the placenta, and a Wassermann 
test upon the mother give negative results. Furthermore, a history 
of the repeated occurrence of premature labor should arouse a similar 
suspicion, and although it may be accounted for by chronic nephritis, 
operations upon the cervix, or even by unusual irritability of the uterus, 
it should lead to the most careful search for syphilis in both parents. 
In my experience the recognition and treatment of this disease is the 
most important matter in connection with the prophylaxis of prema¬ 
ture labor, and until this teaching has permeated the rank and file 
of the profession, large numbers of children will continue to be sacrificed 
unnecessarily. 

Some idea of the importance of syphilis may be gained from the 
fact that in a series of 334 premature labors, I found that it was the 
etiological factor in over 40 per cent., while toxemia, placenta previa and 
foetal deformity were concerned in 8, 6 and 3.3 per cent., respectively. 
Sentex, who studied 485 cases in Pinard’s clinic, arrived at similar 
conclusions and found the underlying cause to be syphilis in 42.7, 
albuminuria in 19.8, and abnormalities of the foetus in 11.1 per cent. 

The figures of Holland, based upon the careful study of 300 foetal 
deaths occurring in London at the time of labor, justify somewhat 
similar conclusions, and at the same time indicate what may be ac- 
complished by proper prenatal supervision and by intelligent care at 
the time of labor. The percentage incidence of the several causes of 
death was as follows: Complications of labor 51, syphilis 16, cause 
undetermined 11, toxemia 10, relative placental insufficiency 6, foetal 
deformity 5, and chronic renal disease 2 per cent. He holds that 52 
per cent, of these deaths could have been prevented—20 per cent, by 
prenatal care alone, 12 per cent, by combined pre-intranatal care, and 
20 per cent, by intranatal care alone. In other words, all of the deaths 
from syphilis and three-fifths of those from toxemia and complications 
of labor could have been avoided—an impressive arraignment of current 
obstetrical practice. 

The course of premature labor differs but little from that of labor 
at full term, except that occasionally the entire product of conception 
is expelled en masse. In other instances, the onset of the accident is 
marked by premature rupture of the membranes and the escape of the 
amniotic fluid. The treatment is identical with that of full-term labor, 
except that when the patient is seen at the beginning of uterine con¬ 
tractions the accident may occasionally be averted by the administration 
of a powerful sedative and absolute rest in bed. The important point, 
however, is to make every effort to ascertain the cause of the accident, 
so that suitable prophylactic measures may be employed to prevent its 
recurrence. 



LITERATURE 


717 


LITERATURE 

Breus. Das tuberose subchoriale Haematom der Decidua. Leipzig u. Wien, 
1892. 

Davidsohn. Zur Lehre von der Mola haematomatosa. Archiv f. Gyn., 1902, lxv, 
181-216. 

Frankel. Ueber Missed Labour und Missed Abortion. Volkmann’s Samml. klin. 
Vortrage, N. F., 1903, No. 351. 

Franque. Ueber liistologische Veranderungen in der Placenta und ihre Bezie- 
hungen zum Tode der Frucht. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 277-298. 

Gottsciialk. Zur Lehre von den Hamatonunolen, etc. Archiv f. Gyn., 1899, xviii, 
134-169. 

Graefe. Ueber Retention des menschlichen Eies im Uterus nach dem Fruchttod. 
Festschrift zu Carl Ruge, Berlin, 1896, 38-79. 

Granville. Graphic Illustrations of Abortion, etc. London, 1834. 

Halban. Zur Behandlung der Fehlgeburten. Zentralbl. f. Gyn., 1921, 439-446. 

Hart. On the Nature of the Tuberous Fleshy Mole. Jour. Obst. and Gyn. Brit. 
Emp., 1902, i, 479-481. 

Holland. Report on the Causation of Foetal Death. Reports on Public Health 
and Medical Subjects. No. 7 Ministry of Health. London, 1922. 

Koebner. Knochenresorption bei intrauterinem Eischwund. Archiv f. Gyn., 1910, 
xci, 109-142. 

Latzko. Die Behandlung des heberhaften Abortus. Zentralbt. f. Gyn., 1921, 
425-439. 

Malins. The Antenatal Waste of Life in Nature and Civilisation. Jour. Obst. 
and Gyn. Brit. Emp., 1903, iii, 307-319. 

Mall. A Study of the Causes Underlying the Origin of Human Monsters. Phila¬ 
delphia (Wistar Institute), 1908. 

On the Frequency of Localized Anomalies in Human Embryos and Infants at 
Birth. Am. J. Anat., 1917, xxii, 49-72. 

Merttens. Beitrage zur normalen und path. Anatomie der menschlichen Pla¬ 
centa. Zeitschr. f. Geb. u. Gyn., 1894, xxx, 1-97. 

Oldham. Missed Labour. Guy’s Hosp. Reports, 1847, 105-112. 

Reynolds and Macomber. Certain Dietary Factors in the Causation of Sterility 
in Rats. Am. Jour. Obst. & Gyn., 1921, ii, 379-394. 

Schottelius. Aborte und Geburtenziffer in Hamburg. Zentral. f. Gyn., 1921, 
70-72. 

Sentex. Des causes de la mort du produit de la conception pendant la grossesse. 
These de Paris, 1901. 

Smith. The Etiological Relation of Spirilla (Vibrio Fetus) to Bovine Abortion. 
Jour. Exp. Med., 1919, xxx, 313-323. 

Stockard. Developmental Rate and Structural Expression; An Experimental Study 
of Twins, “Double Monsters” and “Single Deformities, etc.” Amer. Jour. 
Anat., 1921, xxviii, 115-266. 

Taussig. Haematom Mole. Am. Jour. Obst., 1904, i. 456-472. 

Prevention and Treatment of Abortion, St. Louis, 1910. 

Titus. A Statistical Study of a Series of Abortions. Am. J. Obst., 1912, lxv, 
960-980. 

Veit. Vorzeitige Unterbrechung der Sehwangerschaft. Muller’s Handbuch der 
Geburtshiilfe, 1889, ii, 23-57, 

Walther. Ein Fall von tuberosem, subchorialem Hamatom der Decidua. Zen¬ 
tralbl. f. Gyn., 1892, xvi, 707-710. 






718 


ABORTION, MISCARRIAGE, AND PREMATURE LABOR 

Williams. The Limitations and Possibilities of Prenatal ( are. J. Am. Med. 
Assn., 1915, lxiv, 95-101. 

An Early Ovum in Situ in the Act of Aborting. Trans. Am. Gyn. Soc., 1919, 
xliv, 91-101. 

Williams, W. L. Diseases of the Genital Organs of Animals. Ithaca, 1921, 
Williams and Kolmer. Complement-fixation in Abortions in Women. Am. J. 
Obst., 1917, lxxv, 193-203. 

Winter. Zur Prognose und Behandlung des septische Abortes. Zentralbl. f. 
Gym, 1911, 569-576. 

Young and Williams. 2000 Cases of Miscarriage at the Boston City Hospital, 
Boston. Med. and Surg. Jour., 1911, clxiv, 871-876. 


CHAPTER XXX 



EXTRA-UTERINE PREGNANCY 

In extra-uterine pregnancy the fertilized ovum is arrested at some 
point between the ovary and the uterus, and there undergoes more or 
less complete development. Ectopic gestation , which is sometimes used 
as a synonymous term, has a broader meaning, inasmuch as it includes 
not only the usual forms of extra-uterine pregnancy, but also those in 
which the ovum is implanted in the rudimentary horn of a bicornuate 
uterus, or in a crypt far removed from the uterine cavity in a uterus 
presenting adenomyomatous changes, as described by Doderlein and 
Herrgott. 

For a long time extra-uterine pregnancy was of interest chiefly from 
a pathological point of view, but since 1883, when Tait first operated 
upon a case of ruptured tubal pregnancy, the subject has attained a 
markedly practical interest, as is manifested by the immense literature 
of recent years. This history of its development is treated in detail in 
the monographs of Campbell, Hecker, Parry, Tait, Werth, and Webster. 

Prior to 1876, extra-uterine pregnancy was considered so rare an 
affection that Henning stated that even the directors of large obstetrical 
institutions might never encounter a case, and Parry was able to collect 
only 500 instances from the entire literature. It was only with the 
gradual development of abdominal surgery that its relative frequency 
became recognized and it is now generally admitted that operations for 
extra-uterine pregnancy constitute a small percentage of all gynecological 
laparotomies. Thus, there w r ere fifty operations in the Gynecological 
department of the Johns Hopkins Hospital during the five years ending 
1922; while Wynne states that in the 22,688 patients admitted previous 
to that period the incidence of extra-uterine pregnancy was 1.3 per cent. 

Schumann calculated that the condition was noted once in every 
303 pregnancies occurring in Philadelphia during the year 1918. He 
arrived at this conclusion by obtaining statements from the various 
hospitals and operators as to the number of cases cared for, and 
compared the total thus obtained with the number of births recorded by 
the Health Department. 

Classification—As the fertilized ovum may be arrested at any point 
on its way from the graafian follicle to the uterine cavity, it may undergo 
development in the ovary or in any portion of the tube, giving rise to 
ovarian or tubal pregnancy respectively. It is doubtful whether the 
ovum can become implanted upon the peritoneum and a primary abdom¬ 
inal pregnancy follow. 

Etiology. —According to Leopold, ovarian pregnancy results from 
the fertilization of the ovum before its escape from the graafian follicle. 

719 







720 


EXTRA-UTERINE PREGNANCY 


Moreover, he believed, when several follicles mature at the same time, 
that a deeply lying one may rupture into a more superficial one with¬ 
out the escape of its ovum, in which event the latter may be fertilized 
by spermatozoa entering through the superficial follicle. Such an occur¬ 
rence would afford a satisfactory explanation for a pregnancy occupying 
the central portion of the ovary. 

Unfortunately, equally concise and definite statements cannot be 
made concerning the etiology of tubal pregnancy, although a number 
of explanations, of greater or less plausibility, have been advanced. 
Broadly speaking, these may be divided into three main groups: (1) 
Conditions which interfere mechanically with the downward passage 
of the ovum; (2) Inflammatory diseases of the tubes; (3) Physical and 
developmental abnormalities which favor decidual formation in the 
tubes. 

1. Conditions which Interfere Mechanically with the Downward 
Passage of the Ovum.—(a) Fritze, in 1779, first directed attention to 
the fact that peritoneal adhesions, by compressing the lumen of the 
tube or by interfering with its peristalsis, might cause the arrest of 
the ovum. 

( b ) Leopold, Breslau, Beck, Wyder, and others believed that polypi 
projecting into the lumen of the tube might occasionally interfere with 
the descent of the ovum. It is quite probable, however, that such struc¬ 
tures were not primary, but had appeared only after conception. 

(c) Some observers believe that myomata, or other tumors, situated 
in the wall of the tube or in adjacent organs, may so compress the tubal 
lumens as to interfere with the passage of the ovum. 

(d) Schroeder, in 1887, but more particularly Tait, a few years 
later, advanced the theory that the most frequent etiological factor was 
an endosalpingitis. This they supposed led to the destruction of the 
cilia and the consequent cessation of the downward current, thereby 
allowing spermatozoa to enter the tube. 

This view implied that fertilization normally occurred in the uterine 
cavity, and was based upon the supposition that the ciliary current was 
directed downward in the tubes and from below upward in the uterus, 
the entry of spermatozoa into the uterine cavity being thereby facili¬ 
tated, while their access to the tubes was rendered difficult. After 
Hofmeier and Mandl had demonstrated the fallacy of these suppositions 
by showing that the current extended downward from the fimbriated 
extremity of the tube to the internal os, it became evident that the 
spermatozoa were obliged to contend against it from the time they 
entered the uterus. As it is now known that fertilization occurs normally 
in the tubes, the problem to be solved in every case of tubal pregnancy 
is not how the spermatozoa may have gained access to the tubes, but 
why the fertilized ovum failed to make its way to the uterus. 

Furthermore, the cilia may persist in spite of acute inflammation, 
and I have been able to demonstrate their presence in nearly every preg¬ 
nant tube which I have examined, while Zedel saw them in motion in 
several specimens which he examined in the fresh condition. 

(e) Abel, Kreisch, and others believe that the foetal convolutions of 







ETIOLOGY 


721 


the tube occasionally persist in later life, and hinder the downward 
passage of the fertilized ovum either by constricting the lumen or by 
interfering with peristalsis. 

(/) I 11 1891 Landau and Bheinstein, and I demonstrated the pres¬ 
ence of diverticula from the lumen of the tube, and suggested that a 
feitilized ovum entering such a structure would eventually be arrested 
at its blind end, where it might undergo further development (Fig. 514). 
Specimens, in which the foetal sac lay entirely outside of the lumen of 
the tube, being separated from it by a layer of tissue of varying thick¬ 
ness (see Fig. 520), apparently offered confirmatory evidence of such 
an occurrence. At that time definite information concerning the mode 
of implantation of the ovum was not available, and it was supposed that 
it became implanted upon the surface of the mucosa. When, however, 
Spee's teaching that the ovum immediately burrowed into the depths 



of the mucosa had become generally accepted, it became apparent that 
the presence of the product of conception in the wall of the tube did 
not necessarily prove that it had been implanted in a diverticulum. 
Consequently, while it must be admitted that such an occurrence is pos¬ 
sible, it is difficult to adduce conclusive evidence in its support, unless 
reconstructions are made from serial sections, as was done by Hoehne in 
1917. 

Now and again, in serial sections through the tube, it is possible to 
demonstrate the presence of accessory lumina—long processes, which 
extend from the main lumen and, after continuing parallel to it for a 
considerable distance, rejoin it, or end blindly. In several instances, I 
have noted conditions which seemed to indicate that the fertilized ovum 
had been arrested in such a structure. 

Sometimes accessory ostia, instead of communicating with the lumen 
of the tube, represent mere culsdesac. That the fertilized ovum may be 
arrested in such a structure and go on to further development was 
















722 


EXTRA-UTERINE PREGNANCY 


conclusively demonstrated by Henrotin, Herzog, and Walthard (Fig. 
515). 

( g ) Diihrssen believed that in occasional instances the arrest of the 
ovum may be due to puerperal atrophy of the tube, whereby its normal 
peristalsis remains permanently impaired. Hoehne contends that gen¬ 
eral hypoplasia of the tube may have a similar effect. 

(h) In a considerable number of cases which I have examined, the 
corpus luteum was situated not in the ovary corresponding to the preg¬ 
nant tube, but in the opposite one, indicating that external migration 
had occurred, and that the fertilized ovum had made the transit of the 
pelvic cavity. Sippel believed that such a phenomenon may favor the 
production of extra-uterine pregnancy, since the fertilized ovum may 
attain such proportions during its migration as to interfere with its 
passage through the tube. 

II. Conditions Resulting from Inflammatory Conditions of the 
Tubes. —As has already been said, Schroeder and Tait emphasized the 



Fig. 515.— Pregnancy in Accessory Tubal Ostium (Henrotin and Herzog). 

A , small accessory ostium; B, opening of pregnant ostium; C, blind end of same; D, blood 

clot containing remnants of ovum. 


etiological importance of such conditions. This view is supported by the 
fact that many cases of tubal pregnancy have been preceded by pelvic 
inflammatory trouble, and that a history of gonorrheal salpingitis or of 
inflammatory disease of the appendages can be elicited in a considerable 
proportion of the cases. After it had been demonstrated that the arrest 
of the ovum was not due to the destruction of the cilia by the inflam¬ 
matory process, great difficulty was at first experienced in explaining 
the connection between the two conditions. In 1902, however, Opitz 
noted in many of his specimens that the tips of the folds of the mucosa 
had become fused together, so that the section presented the cribriform 
appearance characteristic of the so-called “follicular salpingitis.” As 
similar lesions were usually present in the non-pregnant tube, he held 
that they afforded a satisfactory explanation for the arrest of the ovum. 
He assumed that some of the canals inclosed between the adherent folds 
communicated freely with the main lumen of the tube, but ended blindly 















ETIOLOGY 


723 


at the other extremity, so that if a fertilized ovum were arrested in such 
a culdesac a tubal pregnancy might develop. 

This explanation was enthusiastically accepted by Werth and Hoehne, 
who considered it of almost universal application. I have frequently 
observed the same condition, and agree with Mall that it is a frequent 
etiological factor. 

III. Physical ancl Develop merital Conditions which Favor Decidual 
Formation in the Tubes. —Webster believed that the explanation for the 
comparatively infrequent occurrence of tubal pregnancy was to be found 
in the fact that the decidual reaction, which he considered essential to 
the proper implantation of the fertilized ovum, is usually lacking. He 
held that the abnormality can come about only when the tubes are 
capable of this reaction, which he considered represents a reversion to 
an earlier type, and therefore should be regarded as a sign of degen¬ 
eracy. This view was indorsed by Pantellani, Mandl and Schmidt, 
Wormser, Moericke, and others, but the belief is based upon theoretical 
considerations rather than upon anatomical observation. 

From what has just been said, it is apparent that there is no lack of 
theories concerning the etiology of tubal pregnancy, and the question 
which we have to consider is which of them is correct, or whether any 
one is of universal application. 

Tainturier, and Mandl and Schmidt approached the problem experi¬ 
mentally by applying ligatures to various portions of the generative 
tract of rabbits shortly after copulation. When applied to one uterine 
cornu some distance below the tubal opening, ova developed distal to 
the ligature, as well as in the normal horn, and when both cornua were 
ligated no ova developed median to the ligatures. On the other hand, 
when the ligatures were applied to the uterine ends of the tubes, extra- 
uterine pregnancy did not develop, although dead ova could be demon¬ 
strated above the ligatures. In a series of control experiments, when 
only one tube was ligated, the same result was obtained on that side, 
while the other uterine horn contained normal embryos. 

These experiments, show conclusively that in the rabbit, at least, some 
factor other than mere mechanical interference with the downward 
passage of the ovum is necessary to the production of tubal pregnancy, 
and this Mandl and Schmidt sought in a preliminary decidual reaction. 
The fact, however, that the decidual formation is never abundant in 
the pregnant tube, and is frequently altogether absent, would militate 
strongly against such a" view. 

The only positive experimental work along these lines was reported 
by Nuck many years ago, but it is probably open to the objection that 
he did not distinguish carefully enough between the cornua and the 
tubes in the bicornuate uterus of the lower animals. 

The idea that tubal pregnancy is a sign of degeneration or reversion, 
while extremely interesting, and to a certain extent borne out by facts, 
cannot be accepted as a universal solution of the problem; for in many 
instances the condition occurs in well developed women who live amid 
the best surroundings. Moreover, its great rarity in the lower animals 
also speaks against such a view. Bland Sutton states that in his large 






724 


EXTRA-UTERINE PREGNANCY 


experience in the zoological gardens of London he has never met with 
tubal pregnancy in animals, and believes that all such cases recorded in 
the literature are due to confounding the uterine cornua with the tubes. 
This statement, however, is too radical, as Waldeyer has reported an 
undoubted case in an ape. 

In view of the considerations just adduced, it is apparent that the 
etiology of tubal pregnancy is not a simple matter, and that there is 
no universal cause for all cases. In many instances, the arrest of the 
ovum in a crypt resulting from follicular salpingitis, or in a diverticulum, 
affords a satisfactory explanation; while the fact that the condition 



Fig. 516. — Dr. E. K. Cullen’s Specimen of Ovarian Pregnancy. X 1. 

occurs much more frequently in urban than in rural districts speaks 
strongly in favor of its inflammatory origin, as the possibility of gonor¬ 
rheal infection is much greater in large cities than in the country. On 
the other hand, in a certain proportion of cases even the most careful 
clinical history and microscopical examination of the specimen will fail 
to reveal a tangible cause for the condition, which will still remain as 
great a problem to us as to our predecessors. 

Ovarian pregnancy was first described in the seventeenth century, by 
Mercerus and St. Meurice, and its possibility was generally conceded 
until 1835, when Velpeau stated that none of the cases which had been 
described up to that time afforded conclusive evidence of ovarian origin. 
Similar views were expressed by Mayer in 1847, and were indorsed by 








OVARIAN PREGNANCY 


725 


Pouchet, Allan Thompson, and others. This skepticism was probably 
justifiable, since^jnost of the early cases collected by Campbell and 
Gurgui were simply dermoid cysts of the ovary. 

With the exception of Mayer, the possibility of ovarian pregnancy 
has always been admitted by the German writers, but was strenuously 
denied until 1901 by the English authorities, particularly by Tait, Web¬ 
ster, and Bland Sutton. 

Indeed, as far as I can ascertain, only 3 cases were reported in Eng¬ 
land during the nineteenth century, namely, 2 by Granville in 1834 and 
1 by Oliver in 1896. In this country most writers have followed the 
English authorities, although Parry admitted its existence and not a 
few operators had reported doubtful cases; but it was not until 1902 that 
Thompson demonstrated a conclusive specimen. 

Up to 1878 there existed no definite criteria by which specimens 
could be judged, and many were described as examples of ovarian preg¬ 
nancy which had no claim to such a title. In that year, however, Spiegel- 
berg formulated certain criteria which he held must be fulfilled in order 
to justify such a diagnosis. He demanded (1) that the tube on the 
affected side be intact; (2) that the foetal sac occupy the position of the 
ovary; (3) that it be connected with the uterus by the ovarian ligament; 
and (4) that definite ovarian tissue be found in its wall. When judged 
by these criteria, the majority of cases which had been described up to 
his time were wanting, and subsequent investigation has shown that a 
number of cases which he considered conclusive are likewise open to 
very considerable doubt. 

At present the possibility of ovarian pregnancy is universally ad¬ 
mitted, and even so rigorous a critic as Webster has abandoned his 
skepticism, and has reported two authentic cases. 

I have carefully gone over the literature upon ovarian pregnancy, 
and have classified the cases reported up to January, 1906, as positive, 
highly probable, fairly probable, and doubtful, according to the extent 
to which Spiegelberg’s criteria were fulfilled. I was able to find 13 
specimens belonging to the first category, which were thoroughly de¬ 
scribed, and so carefully studied microscopically that their ovarian origin 
was conclusively demonstrated; namely, the cases of Gottschalk, 1893; 
Ludwig, 1896; Kouwer and Tussenbroek, 1899; Croft, 1900; Anning 
and Little wood, 1901; Robson, 1902; Franz, 1902; Thompson, 1902; 
Mendes de Leon and Holleman, 1902; Micholitsch (2 cases), 1903; 
Boesebeek, 1904; and Webster, 1904. The patients of Gottschalk and 
Ludwig had gone to term, but in none of the other 11 had the preg¬ 
nancy progressed beyond the fourth month. Since then many more 
positive cases have been described, so that Lockyear, when reporting two 
personal cases in 1917, was able to increase the number to forty-one. 
Meyer and Wynne have since reported an additional case and analyzed 
the literature up to 1919. 

It is interesting to note that in one third of the positive or highly 
probable cases, which I collected, the pregnancy had gone to full term, 
and in several instances had eventuated in the formation of 1 it hoped i a, 
which had been carried for years before being removed. This would 


726 


EXTRA-UTERINE PREGNANCY 


appear to indicate that the ovary can accommodate itself more readily 
than the tube to the growing pregnancy; but at the same time it should 
be remembered that rupture at an early period is the usual termination. 
It is also important to bear in mind that the pregnancy may be de¬ 
stroyed at any early period without rupture, and give rise to a tumor of 
varying size, consisting of a capsule of ovarian tissue inclosing a mass 
made up of blood and chorionic villi, which may or may not contain an 
amniotic cavity, as in the specimens of Mendes de Leon and Webster. 
Such observations render it probable that a certain proportion of ovarian 
hematomata may actually represent the remains of an early pregnancy, 
but such a diagnosis should not be considered unless microscopical exami¬ 
nation reveals the presence of chorionic villi. 

In ovarian pregnancy, the ovum itself and its mode of implantation 



Partially separated 
placenta. 


Amnion. 


Cervix. 


Uterine cavity. 


Fig. 517. —Interstitial Pregnancy (Bumm). 


do not differ eventually from that observed in the uterus, except that a 
definite decidual membrane is lacking, so that the foetal ectoderm invades 
the ovarian stroma directly. 

Tubal Pregnancy—In this, by far the most frequent, variety of 
extra-uterine pregnancy, the ovum may develop in any one of the three 
portions of the tube, giving rise to interstitial, isthmic, or ampullar 
pregnancy respectively. In rare instances it may be implanted upon 
the fimbriated extremity, and occasionally even upon the fimbria ovarica. 
From these primary types certain secondary forms—tubo-abdominal, 
tubo-ovarian, and broad-ligament pregnancy—occasionally develop. 

According to Rosenthal, the interstitial is the rarest variety, having 
occurred in only 3 per cent, of the 1,324 cases of tubal pregnancy which 
he collected from the literature. Lequex was able to collect 75 cases 








TUBAL PREGNANCY 


727 


up to 1911, which were still further increased by Wynne in 1918. Of 
146 personal cases analyzed by Hartmann and Bergeret, 119 were ampul¬ 
lar, 24 isthmic, and only 3 were interstitial. Most recent writers state 
that the ampullar variety is the commonest, and this has also been my 
experience. 

Anatomical Considerations .— (a) Mode of Implantation of the Ovum. 
—Formerly it was taught that the implantation of the ovum, whether 
in the uterus or tube, was dependent upon the formation of a well- 
developed decidua. The pioneer work of Graf Spee and Peters, however, 
has demonstrated that even in the uterus this is not necessary, as the 
ovum burrows down into the depths of an edematous endometrium, 
whose stroma cells have not yet assumed a characteristic decidual ap¬ 
pearance. This work, which has completely revolutionized our con¬ 
ception of the mode of implantation of the ovum in uterine pregnancy, 
applies equally well to the tube, although certain anatomical peculiarities 
of the latter usually necessitate a different outcome. 

The ovum may become arrested in any portion of the tube, and, 
according to Werth, may become implanted in either one of two ways. 
In the first, or columnar, variety, which is very rare, the ovum becomes 
attached to the tip or side of one of the folds of the mucosa; while in 
the second, or intercolumnar variety, implantation occurs at the periph¬ 
eral portion of the lumen in a depression between two folds. In either 
event, the ovum does not remain upon the surface, but at once burrows 
through the epithelium, and comes to lie in the tissue just beneath it. 
At that time its periphery is made up of a capsule of rapidly proliferating 
trophoblast, whose cells soon invade the surrounding tissues. The in¬ 
vasive and arrosive properties of these ectodermal cells bring about de¬ 
generation of the muscle and connective-tissue cells, which eventually 
become converted into fibrin. At the same time maternal blood vessels 
are opened up, and the blood is poured out into spaces of varying size 
lying entirely within the trophoblast, or between it and the adjacent 
tissue. Young considers that edema and necrosis occur before the ma¬ 
ternal tissue is reached by the foetal cells, and are probably due to the 
action of chemical substances secreted by the latter. 

In the usual, intercolumnar mode of implantation, owing to the 
: absence of a submucosa and the lack of development of a decidual mem¬ 
brane in the tube, as soon as the ovum penetrates the epithelium it comes 
to lie in the muscular wall, and is separated from the lumen by a layer 
! of tissue of varying thickness—the capsular membrane or pseudoreflexa 
(Fig. 520). On the other hand, in the rare columnar mode of implanta¬ 
tion, the ovum lies in the interior of a fold of mucosa, and except at 
its base is surrounded on all sides by tubal epithelium, so that it has but 
slight space for expansion. 

Every specimen of early tubal pregnancy, which I have studied in 
recent years, has served to strengthen my belief that implantation occurs 
in practically the same manner as in the uterus. That this view is 
correct is shown by the fact that it has been endorsed by all subsequent 
investigators, who are now too numerous to mention. 

The further development of the pregnancy depends in great part 




728 


EXTRA-UTERINE PREGNANCY 


Dec. 


upon the portion of the tube in which implantation has occurred. When 
in the ampulla, the growing ovum pushes forward the capsular membrane 
into the tubal lumen, and the latter may eventually become so compressed 
as to appear as a mere crescentic slit. If the course of the pregnancy 
be not interrupted, the capsular membrane may fuse with the neighboring 
mucosa, so that the lumen of the tube becomes obliterated in the im¬ 
mediate vicinity of the ovum. 

On the other hand, when implantation occurs in the isthmus, and 
particularly in the portion immediately adjoining the uterus, the small 



w ■ -« • ^' 




Fig 518. —Section Showing Attachment of Chorion to Tube Wall. X 90. 
Dec., decidual cells, L. C., Langhans’ cells, Syn., syncytium, V., villi. 


size of the lumen precludes the possibility of such expansion. As a 
consequence the ovum distends the tube wall peripherally, so that the 
lumen may eventually become completely separated from the underlying 
muscularis and be surrounded by foetal tissue and villi, with the result 
that intraperitoneal rupture frequently occurs before the patient is aware 
that she is pregnant. 

(b) Decidua .—Bland Sutton in 1891, and Fiith and Griffiths a few 
years later, pointed out that the decidual reaction in the tube was nothing 
like so extensive as was generally believed; while Kiihne, Aschoff, and 
Ivreisch were skeptical of its existence, and contended that the cells, 
which had formerly been described as decidual, were really of foetal 







TUBAL PREGNANCY 


729 


origin. The first mentioned view has been confirmed, by subsequent 
observers, and at present no one claims that a continuous decidual mem¬ 
brane is formed. 

On the other hand, it is erroneous to contend that a decidual reaction 
is always lacking, as it is possible by careful study to distinguish decidual 
cells, and to differentiate clearly between them and foetal cells. The 
former are usually found in discrete patches in the tips of some of the 
folds of the mucosa in the neighborhood of the ovum. Furthermore, 
one can occasionally find decidual cells scattered between the foetal tissues 



Fig. 519. —Section Showing Formation of Decidual Cells in Non-pregnant Tube, 
Demonstrating that They Could not Be of Fcetal Origin. 

m.m., tubal mucosa; muse., muscularis; d, decidua. 

at the placental site (Fig. 518), but I have never observed a decidual 
membrane analogous to the decidua vera or serotina in uterine pregnancy. 

That the authors who deny the existence of decidual cells in the 
tube take too extreme a view is shown by the fact that they have been 
repeatedly observed by Webster, Both, Couvelaire, Kermauner, Young, 
myself, and others. Moreover, the possibility of a decidual reaction is 
demonstrated by the fact that I have repeatedly observed characteristic 
decidual cells in the non-pregnant tube (Fig. 519). Observations of 
this character are beyond criticism, as in such cases it is impossible to 


730 


EXTRA-UTERINE PREGNANCY 



confuse decidual with foetal cells. Furthermore, Mandl, Lange, and I 
have noted an identical reaction in the tubes in certain cases of uterine 


pregnancy. 

The absence, or comparative scantiness, of the decidual reaction is of 
interest not only from a scientific point of view, but also has a distinctly 
practical bearing, as it would seem to offer a satisfactory explanation for 
the invasion and destruction of the tube wall by the foetal elements. 
In uterine pregnancy, such an invasion is noted only in the rare in¬ 
stances in which there is an imperfect development of the decidua, and 
it would therefore appear that one of the main purposes of its formation 
is to protect the maternal tissues against the invasive and corrosive 
action of the foetal cells. 

(c) Decidua Capsularis. —Since the time of Rokitansky, the question 

as to the existence 


of a decidua cap¬ 
sularis in tubal 
pregnancy has 
been repeatedly dis¬ 
cussed, one set of 


investigators claim¬ 


ing that it is usu¬ 


ally present and the 
other set holding 
that it is always 
absent. The inves¬ 
tigations of the past 


few years have 








served to reconcile 
these differences. 

In view of the 
general scantiness 
of the decidual re¬ 
action, it is evident 
that one could not 
reasonably expect 
the formation of a 
structure identical 
Avith the decidua 
capsularis of uter¬ 
ine pregnancy. On 

the other hand, in all intact early tubal pregnancies, the ovum is sepa- 
lated fiom the lumen of the tube by a thicker or thinner layer of connec¬ 
tive and muscular tissue, which may contain a few isolated decidual cells 
(Fig. 520). As the pregnancy advances this membrane becomes invaded 
by foetal cells, undergoes fibrinous degeneration, and, if rupture does 
not occur, e\entually fuses with the mucosa of the opposite side of the 
tube. As this structure is only superficially analogous to the decidua 
capsulaiis, it is better designated as the pseudocapsularis or capsular 


Fig. 520.—Early Tubal Pregnancy, Showing Ovum Em¬ 
bedded in Wall of Tube Outside of Lumen. X 6. 
6.c., blood clot; v., chorionic villi; reft., capsular membrane. 


membrane. 








TUBAL PREGNANCY 


731 


( d) Placenta. —As the early stages of the development of the placenta 
are identical in both tubal and uterine pregnancy, the different outcome 
in the former is dependent upon the absence or scanty development 
of a decidual reaction. As a consequence, the tissues of the tube wall 
in contact with the ovum offer but slight resistance to the invasive 
properties of the foetal elements, and soon undergo degenerative change. 
The chorionic villi and foetal cells invade this tissue, almost like a 
malignant growth, and at the same time open up maternal blood vessels. 
In many cases they penetrate directly through the peritoneal surface 
or through the capsular membrane, and give rise to intraperitoneal 
rupture or tubal abortion, as the case may be. In other instances, 
however, early rupture is due to the sudden opening up of a large vessel, 
when the weakened tube walls yield to the increased pressure. Werth 
has quaintly expressed the process by stating that the ovum, in making 
its bed, digs its own grave. 

The microscopic structure of the foetal portion of the placenta is 
identical with that observed in uterine pregnancy. Even more frequently 
than in that condition, masses of Langhans 7 cells, syncytium, or even 
fragments of villi become broken off, and are carried by the veins to 
various portions of the body. This process of deportation can be shown 
m almost every specimen by cutting serial sections. Yeit has still 
further extended this conception by applying it to the growth into venous 
channels of chorionic villi, which still retain their connection with the 
placenta. He considers that it plays an important part in the production 
of rupture, as such a clogging of the venous channels may so raise the 
pressure in the intervillous spaces that the weakened tube walls neces¬ 
sarily give w^ay. 

It is stated by Gubb and others that the placenta may continue to 
grow after the death of the foetus. I, however, agree with Berry Hart, 
that it is improbable, except in the rare cases of hydatidiform mole 
formation; although it must be admitted that in advanced tubal preg¬ 
nancy hemorrhage into the placenta may lead to a considerable increase 
in its size. 

( e) Structure of the Foetal Sac .—In tubal pregnancy there is a 
marked increase in the vascularity of the affected tube, the larger arteries 
and veins being much hypertrophied, while the smaller vessels, especially 
in the neighborhood of the placental site, are markedly engorged. 

Microscopical sections through the sac in the early months show 
a slight hypertrophy of the muscle cells, but no apparent increase in 
their number. Except at the placental site, the tube wall is considerably 
thickened, and its cells are spread apart by edema. At a still more 
advanced period, the muscular constituents of the gestation sac appear 
to diminish in number, so that at full term almost its entire thickness 
is made up of a connective tissue poor in cells, with only here and there 
a muscle fiber. This indicates that the muscularis of the tube does 
not possess the same tendency to hypertrophy as that of the uterus, 
though occasionally it is quite marked, Pinard having reported a case 
in which the foetal sac contracted so strongly that he mistook it for 
a pregnant uterus. 








732 


EXTRA-UTERINE PREGNANCY 


In most cases the exterior of the tube gives evidence of peritonith 
involvement, and a considerable portion of the thickness of the fceta 
sac is often due to peritoneal adhesions. 

In order for complete tubal abortion to occur, the fimbriated ex 
tremity must remain patent, but in other cases its condition varies 
being sometimes closed, sometimes open. As a rule, the lumen of th« 
tube communicates directly with either end of the foetal sac. Les, 
commonly, however, this communication is noted only at one end, whili 
still more rarely the foetal sac is completely shut off from the mail 
lumen. A satisfactory explanation of these differences has not yet beei 
adduced. 

(/) Uterine Changes .—In the first three months the uterine under 
goes considerable hypertrophy, and its endometrium becomes converte( 

into a structure similar to the de 
cidua vera observed in uterine preg 
nancy, and differing from it only i; 
a less marked development of th 
spongy layer and $ greater abund 
ance of blood spaces just beneatl 
its free surface. Careful study o 
its histological structure was re 
ported by Sampson in 1915. Soo] 
after the death of the foetus, th 
decidua degenerates and usuall 
comes away in small pieces, bu 
occasionally it is cast off intact, rep 
resenting a triangular cast of th 
uterine cavity. Its discharge i 
usually considered of marked diag 
nostic significance; so much so tha 
in doubtful cases many observer 
recommend curetting the uterus, am 
base their diagnosis upon the pres 
ence or absence of decidual tissue. 

Terminations of Tubal Preg 
nancy. —According to Tait, the uni 
veisal fate of tubal pregnancy was rupture either into the peritonea 
cavity, or between the folds of the broad ligament, occurring not late 
than the twelfth week. Wider experience has demonstrated the incorrect 
ness of his teachings, as more than one-half of the cases terminate at a] 
eaily period by aboition after rupture through the capsular membrane 
Very exceptionally, the pregnancy may go on to full term without rup 
ture, as I have observed in several instances. 

(a) Tubal Abortion (Intratubal, or Capsular Rupture). —Aftei 
Werth, in 1887, had directed attention to the possibility of tubal abor 
tion, it has gradually become established that this is the most frecjuen 
outcome of tubal pregnancy. The marked change of opinion whicl 
has taken place upon this point is readily appreciated by comparing 
the statements made by Schrenck and Werth, in 1892 and 1904, ^ 



Fig. 521. —Uterine Decidua from a 

Case of Extra-uterine Pregnancy 
(Zweifel). 








TUBAL PREGNANCY 


733 




spectively. The former found only 6 cases of abortion in 610 cases 
of tubal pregnancy collected from the literature; whereas the latter 
stated that seven out of eight cases ended in that way as compared to 
one by rupture. 



The frequency of tubal abortion depends in great part upon the site 
of implantation of the ovum. In ampullar pregnancy, it is the general 


Fig. 522. —Early Tubal Pregnancy, with Abortion of Ovum into Lumen of Tube. 




X 6. 


b.c., blood clot; v ., chorionic villi. 


rule, whereas intraperitoneal rupture is the usual outcome in isthmic 
pregnancy. This difference is due to the fact that in the former location 
the tubal lumen is sufficiently capacious to permit of a considerable 
degree of expansion of the foetal sac, whereas in the latter the lumen 
is so smal] that this is impossible; and as expansion can occur only 
toward the periphery, early rupture is the usual termination. 

Tubal abortion results from the perforation or rupture of the cap¬ 
sular membrane or pseudoreflexa by the growing chorionic villi, and 














734 


EXTRA-UTERINE PREGNANCY 


therefore does not differ essentially from intraperitoneal rupture, except 
in the fact that in one case the accompanying hemorrhage occurs into 
the lumen of the tube, whereas in the other it takes place into the 
peritoneal cavity. Accordingly, the term “tubal abortion” could be well 
replaced by that of intratubal rupture, as suggested by Berkeley and 
Bonney. 

The immediate consequence of the hemorrhage is the loosening of 
the connection between the ovum and the tube wall, the former becoming 
completely or partially separated from its site of implantation. In the 
former case, the entire ovum is extruded into the lumen of the tube, 
and is gradually forced by the effused blood toward the fimbriated end, 
through which it may be extruded into the peritoneal cavity, whereupon 
the hemorrhage usually ceases. In the latter event, on the other hand, 
the ovum remains in situ, and the hemorrhage continues. Accordingly, 



Fig. 523. —Tubal Abortion, Ovum Being Extruded through Fimbriated Extremity 

(Kelly). X 1. 

we distinguish between complete and incomplete abortions, the latter 
occurring ten times more frequently than the former, according to 
Wormser. 

In a small number of cases the ovum may be observed in the act of 
abortion (Fig. 523). Thus, among my own specimens are several which 
show the foetus surrounded by its membranes, protruding from the 
dilated fimbriated extremity of the tube. 

When the hemorrhage is moderate in amount and the ovum remains 
in situ, it may become infiltrated with blood and become converted into 
a structure analogous to the blood or fleshy mole observed in uterine 
abortions (Fig. 524). The hemorrhage usually persists as long as the 
mole remains in the tube, and the blood slowly trickles from the fimbri¬ 
ated extremity into Douglas’ culdesac, where it becomes encapsulated, 
giving rise to an hematocele. If the fimbriated extremity is occluded, 
the tube may gradually become distended by blood— hematosalpinx. 



TUBAL PREGNANCY 


735 


After incomplete abortion, small particles of the chorion may remain 
attached to the tube vail and, becoming surrounded by fibrin, give rise 

to a placental polypus, just as is often noted after an incomplete uterine 
abortion. 




T. 


Fig. 524.— Section through Tubal 
Mole. X 1. 

B.C., blood clot; Ov., ovum; T.W., tube 
wall; U.T., uterine end of tube. 


(/;) Rupture into the Peritoneal Cavity. —Less than one half of the 
cases of tubal pregnancy end within 
the first twelve weeks by intra- 
peritoneal rupture, which usually oc¬ 
curs spontaneously, but occasionally 
is the result of violence. Generally 
speaking, when rupture occurs in 
the first few weeks, the pregnancy 
is situated in the isthmic portion 
of the tube, a short distance from 
the cornu of the uterus (Fig. 525). 

On the other hand, when the ovum 
is implanted in the interstitial por¬ 
tion of the tube, rupture usually 
does not occur until after the fourth 
month, and sometimes considerably 
later. This difference is due to the 
fact that the tiinterstitial portion 
of the tube is surrounded by a thick 
layer of uterine musculature, which 
reacts promptly to the stimulation 
of pregnancy, and by its hypertrophy allows the ovum to attain a con¬ 
siderable size before rupture occurs. 

The prime factor in the causation of rupture is the intramural 
embedding of the ovum, and the consequent invasion of the tube wall 
by chorionic ectodermal elements, with consequent fibrinoid degeneration 
of the muscular layer. Its direct cause may be violence, such as vaginal 
examination, coitus, a fall, or even mere overexertion, though in the 

great majority of cases it occurs 
spontaneously. In the latter 
event, rupture is brought about 
either by direct perforation by the 
growing villi, or by the weakened 
tube wall yielding to a sudden in¬ 
crease of pressure in the inter¬ 
villous spaces, following the sud¬ 
den opening up of a large vessel 
or the clogging of venous chan¬ 
nels by chorionic villi. The evidence at present available seems to 
indicate that the latter is the more usual factor. 

If rupture occurs in this way in an otherwise normal tube, it is 
apparent that it will be likely to occur at a much earlier period if the 
ovum be arrested in a diverticulum from its lumen, as in such cir¬ 
cumstances it will have only a portion of the tube wall to penetrate, 
instead of its entire thickness. 


Fig. 525.—Isthmic Pregnancy, Rupture 
Ten Days after Last Menstrual Pe¬ 
riod. X 1. 


736 


EXTRA-UTERINE PREGNANCY 


Occasionally, when the fimbriated end of the tube is occluded, 
secondary rupture may occur after a primary abortion. In such cir¬ 
cumstances the weakened tube wall yields to the pressure of the blood, 
which has been poured into its lumen and can find no other means 
of escape. 

Rupture usually occurs in the neighborhood of the placental site, 
and either into the peritoneal cavity or between the folds of the broad 
ligament, depending upon the original site of the ovum. The termina¬ 
tions of the two conditions differ so markedly that it will be necessary 
to consider them separately. 

In intraperitoneal rupture, the entire ovum may be extruded from 
the tube, but if the rent be small, profuse hemorrhage may occur 
without its escape. In either event, the patient immediately shows 
signs of collapse. If death from hemorrhage does not follow, the effect 
of rupture varies according to the amount of damage sustained by the 
ovum. If expelled intact into the peritoneal cavity, the death of the 



Fig. 526. —Ruptured Ampullar Pregnancy. X 1. 

Am,., amnion; O., ovary; P., placenta; T., uterine end of tube. 


foetus is inevitable; and unless the pregnancy has advanced beyond the 
third month, the product of conception will be rapidly absorbed, as was 
shown by Leopold’s experiments upon animals. 

It is still thought by many that in such circumstances the placenta 
may become attached to any portion of the peritoneal cavity, and there 
establish vascular connections, which will render further development 
possible. I do not believe that this can occur, as it is improbable that 
such connections could be established before the ovum had become irre¬ 
parably damaged, not to speak of the negative evidence afforded by 
Leopold’s experiments. 

On the other hand, if only the foetus escapes at the time of rupture, 
the effect upon the pregnancy will vary according to the extent of injury 
sustained by the placenta. If much damaged, death of the foetus and 
termination of the pregnancy is inevitable; but if the greater portion 
of the placenta still retains its attachment to the tube, further develop¬ 
ment is possible, and the foetus may go on to full term, giving rise 
to a secondary abdominal pregnancy. In such cases, the tube may close 








TUBAL PREGNANCY 


737 


down upon the placenta and form a sac, in which it remains during 
the rest of the pregnancy. Or, while a portion of the placenta remains 
attached to the tube wall, its growing periphery extends beyond it and 
establishes connections with the surrounding pelvic organs. Under such 
circumstances one may find the placenta attached partly to the uterus, 
pelvic floor, rectum, or even the intestines. 

I do not believe, however, that the placenta can become solely and 
directly attached to organs far removed from the pelvic cavity, such 
as the stomach and diaphragm, for instance; and when such connections 
are observed, I consider that one has to deal with a broad-ligament 
pregnancy, which had become adherent to the organ in question, and 
that the placenta will be found to be attached to the inner surface 
of the foetal sac adjacent to the adhesion. 



Fig. 527. —Broad-Ligament Pregnancy (Zweifel). 


When the foetus escapes from the tube, following rupture, it is nearly 
always surrounded by its membranes, and most authoiities believe that 
further growth is impossible, unless it is surrounded by the amnion, 
though several cases have been reported in which a full-term foetus lay 
perfectly free in the peritoneal ca\ity, and all that was left of it?? 
membranes was found in the tubal sac. 

(c) Rupture into the Broad Ligament .—In a small number of cases, 
especially when the original insertion of the ovum was basiotropic, as 
Lichtenstein designates it, rupture may occur at the portion of the tube 
uncovered by peritoneum, so that the contents of the gestation sac are 
extruded into a space formed by the separation of the folds of the 
broad ligament. Generally speaking, this is the most favorable variety 
of rupture, and may terminate either by the death of the ovum and 
the formation of a broad-ligament hematoma, or by the fuithei de¬ 
velopment of the pregnancy. 






738 


EXTRA-UTERINE PREGNANCY 


The outcome depends largely upon the degree of completeness with 
which the placenta has been separated. If it still remains attached to 
the interior of the tube, it generally becomes displaced upward as preg¬ 
nancy advances, and comes to lie above the foetus; but when it is situ* 
ated near the point of rupture it gradually extends down between the 
folds of the broad ligament, being implanted partly upon the interior 
of the tube and partly upon the pelvic connective tissue. In either 
event, the foetal sac lies entirely outside of the peritoneal cavity, and 
as it increases in size the peritoneum is gradually dissected up from 
the pelvic and abdominal walls. This condition is designated as extra- 
peritoneal or broad-ligament pregnancy , and was carefully studied by 
Dezeimeris in 1836. Occasionally, the broad-ligament sac may rupture 
at a later period, and the child be extruded into the peritoneal cavity, 
while the placenta retains its original position— secondary abdominal 
pregnancy. 

The importance of rupture into the broad ligament was particularly 
emphasized by Tait, who believed that it was only under such circum¬ 
stances that extra-uterine pregnancy could go on to full term. But 
since a certain number of cases of tubal pregnancy go on to term without 
rupture, it is evident that his statements were based upon imperfect 
information. The frequency of this mode of rupture has been consid¬ 
erably overestimated, as it was noted in only 4 out of 276 cases collected 
from the articles of Mandl and Schmidt, Kiistner, and Fehling. 

The so-called tubo-uterine pregnancy results from the gradual exten¬ 
sion into the uterine cavity of an ovum which was originally implanted 
in the interstitial portion of the tube. Tubo-abdominal pregnancy, on 
the other hand, is derived from a tubal pregnancy in which the ovum 
has been inserted in the neighborhood of the fimbriated extremity, and 
gradually extends into the peritoneal cavity. In such circumstances, 
the portion of the foetal sac projecting into the peritoneal cavity forms 
adhesions with the surrounding organs, which often seriously compli¬ 
cate its removal at operation. Neither of these conditions is common, 
nor do they deserve to be classified- separately; in reality, they are 
merely pregnancies developing at unusual portions of the tubes. 

The term tubo-ovarian pregnancy is employed when the foetal sac is 
composed partly of tubal and partly of ovarian tissue. Such cases owe 
their origin to the development of an ovum in a tubo-ovarian cyst, or 
in a tube whose fimbriated extremity was adherent to the ovary at the 
time of fertilization. They are therefore primarily either tubal or 
ovarian in origin. 

Abdominal Pregnancy.—In the earlier literature it was generally 
stated that the ovum could be implanted upon any portion of the peri¬ 
toneum, giving rise to a primary abdominal pregnancy, and in Hecker’s 
statistics it was recorded twice as frequently as the tubal variety. Later, 
however, when the specimens were more carefully studied, it became 
apparent that the great majority of abdominal pregnancies were sec¬ 
ondary in character, having resulted from ruptured tubal pregnancy. 

Gradually doubt began to be cast upon the existence of primary 
abdominal pregnancy, so that at present most authors, while admitting 




ABDOMINAL PREGNANCY 


739 


its theoretical possibility, are extremely skeptical as to its actual oc¬ 
currence. Bland Sutton positively denies its occurrence in women, and 
contends that it is not observed in the lower animals. Hirst and Knipe, 
Walker, and Jacquin have, however, described specimens, which, while 
not entirely convincing, so nearly fulfill the requisite criteria that it 
became necessary to reckon with this variety of extra-uterine pregnancy 
from a practical point of view. 

Occasionally, as was shown by Zweifel, Martin, Voigt, Leopold, and 
Werth, the fertilized ovum may become implanted upon the fimbria 
ovarica. Such conditions may closely resemble primary abdominal preg¬ 
nancy, inasmuch as the surface upon which the ovum was primarily 
implanted is so small that the margins of the placenta soon extend 
beyond it and become attached to the surrounding organs, thus giving 
the impression that the peritoneum was the original site of implanta¬ 
tion. A careful microscopical examination, however, will usually enable 
one to differentiate between the two conditions. 

Fate of Extra-uterine Foetus.—In the rare instances in which an 
unruptured tubal pregnancy goes to term, the foetus usually presents 
some abnormality, which is often attributed to pressure. On the other 
hand, absorption is the universal fate of small embryos which are ex¬ 
truded into the peritoneal cavity, unless the placenta retains its attach¬ 
ment to the tube wall and still offers conditions suitable for the con¬ 
tinuance of the circulation. Moreover, the young foetus is frequently 
absorbed while still within the tube, as is shown by the fact that, upon 
opening early gestation sacs, it is sometimes represented by an amor¬ 
phous mass of tissue attached to the umbilical cord. At times the only 
indication of its previous existence is found in a small stub of cord 
hanging free in the amniotic cavity. 

Mall, who has directed particular attention to the condition of the 
foetus while still within the tube, believes that it is particularly prone 
to abnormal development. In 117 specimens he found only 16 normal 
embryos, and, as rupture is more likely to occur under such conditions, 
he has calculated that in all probability not more than one per cent, of 
all extra-uterine pregnancies will reach full term. Furthermore, when 
the foetus has attained a certain size before death it cannot be absorbed, 
and must undergo suppuration, mummification, calcification, or adi- 
pocere transformation. Pyogenic bacteria often gain access to a gesta¬ 
tion sac, which is adherent to the intestines, and give rise to suppuration 
of its contents. Eventually the abscess perforates at the point of least 
resistance, and if the patient does not die from septicemia, portions of 
the foetus may be extruded through the abdominal wall or into the 
intestines or bladder, according to the situation of the perforation. This 
outcome is particularly frequent in broad-ligament pregnancies, on ac¬ 
count of their proximity to the rectum. 

Mummification and lithopedion formation have already been referred 
to in the chapter on Abortion, and are dealt with fully in Kiichem 
meister’s article. The latter is generally regarded as the most favorable 
of the possible eventualities in cases of advanced extra-uterine preg¬ 
nancy, as in many instances the calcified product of conception may be 









740 


EXTRA-UTERINE PREGNANCY 


carried for years as a benign foreign body, and do no harm unless i' 
gives rise to dystocia in a subsequent pregnancy. In several instance* 
a lithopedion has been known to remain in the abdomen for fifty years 
and the literature contains numerous cases in which a period of twenty 
to thirty years elapsed before its removal at operation or autopsy. 

Much more rarely the foetus may become converted into a yellowish 
greasy mass to which the term adipocere is applied. The fatty materia] 
is supposed to be an ammoniacal soap, but a satisfactory explanation of 
its formation has not as yet been advanced. 

Diseases of Extra-uterine Ovum .—If an extra-uterine pregnancy goe^ 
on without interruption beyond the first few weeks, the ovum is exposed 
to all the diseases which may occur in the ordinary uterine form. Thus, 
Schauta, Wertheim, and Micholitsch have rescribed tubal ova which had 
become converted into hematoma moles. Hydatidiform moles have been 
observed by Otto, Recklinghausen, Wenzel, Sykow, and others; and 
hydramnios by Teuffel, Webster, and others. Meyer’s statement that 
he found hydatidiform mole formation in 48 out of 104 pathologic 
tubal pregnancies can not be accepted without question. In my opinion 
he has described as such the myxomatous degeneration of the stroma ol 
the chorionic villi, which so often occurs in degenerating pregnancies, and 
failed to lay stress upon the proliferation of the chorionic ectoderm, 
which is the characteristic feature of hydatidiform mole. Ahlfeld and 
Marchand first described a case of chorio-epithelioma following tubal 
pregnancy, and Risel, in 1905, was able to collect ten additional cases 
from the literature. It is interesting to note that Spiegelberg and 
Holst observed the occurrence of eclampsia during the false labor in 
cases of advanced extra-uterine pregnancy. 

Symptoms.—Unfortunately, the manifestations belonging to an unin¬ 
terrupted extra-uterine pregnancy are not characteristic, and the patient 
and her physician are frequently unaware of the existence of any ab¬ 
normality until death of the foetus, rupture, or tubal abortion occurs. 
Ordinarily the patient considers herself pregnant, presents the usual 
subjective symptoms, and possibly suffers from slight pains in one or 
other ovarian region, which she regards as the usual concomitants of her 
condition. In rare instances, indeed, she may have no idea that she is 
pregnant, and rupture may occur and perhaps prove fatal, even before 
she has missed a single menstrual period. 

Suppression of the menses is not associated so regularly with this 
condition as with normal pregnancy, being noted in only one-half of 
Brady s cases. These statements, however, do not carry as much weight 
as would appear at first sight, for frequently the hemorrhage does not 
represent a genuine menstrual flow, but is due to the fact that the 
dilated vessels in the uterine decidua are not covered by a layer of 
foetal tissue. Moreover, the death of the extra-uterine foetus, if not 
accompanied by rupture or abortion, is usually associated with more or 
less uterine hemorrhage, which is frequently mistaken for the menstrual 
flow or for an early abortion, the latter belief being still further con¬ 
firmed by the discharge of decidua. 

In many cases the first manifestation of the abnormal pregnancy is 



SYMPTOMS 


741 


the sudden occurrence of intense, lancinating pain in one or other 
ovarian region, which is soon followed by faintness, the patient rapidly 
passing into a condition of collapse. This indicates the occurrence of 
rupture or abortion. In the former case the collapse deepens, the face 
becomes pallid, and the patient complains of intense pain in the lower 
abdomen. The temperature may be subnormal, and an examination of 
the blood shows a marked diminution in the number of red corpuscles 
and in the amount of hemoglobin. Death may occur within a few 
hours unless the hemorrhage is checked by operative means. On the 
other hand, in most cases of tubal abortion, the general condition is 
not so alarming, the patient rallies promptly, gradual recovery ensues, 
and a few days later vaginal examination frequently reveals the presence 
of a fluctuant mass which fills a greater or lesser portion of the pelvic 
cavity —pelvic hematocele. 

Formerly hematocele was considered as a distinct disease, and it was 
mainly owing to Veit’s observations that its connection with extra- 
uterine pregnancy was established. It is described as diffuse or solitary , 
according as the collection of blood occupies a considerable portion of 
the pelvic cavity or is confined to the neighborhood of the fimbriated 
end of the tube. The diffuse variety usually occurs when preexisting 
adhesions about the pelvic organs facilitate the coagulation of blood 
and aid in the formation of an organized membrane over it, thus shutting 
it off from the peritoneal cavity. According to Sanger, the solitary 
hematocele does not require the presence of adhesions for its formation, 
but results from the gradual trickling of blood from the fimbriated 
end of the tube, the outer portions gradually coagulating and becoming 
organized, thus forming a capsule which slowly expands as more blood 
escapes. 

Hematocele formation, for the most part, promises a very favorable 
termination, for if left alone the mass gradually undergoes absorption 
and complete recovery occurs. Thorn has reported 157 cases with two 
fatalities, and Fehling 91 cases without a single death. Occasionally, 
however, if the hemorrhage persists, the hematocele increases in size 
until it finally ruptures and its contents are poured out into the peri¬ 
toneal cavity. Such an accident is speedily followed by collapse. Again, 
bacteria sometimes make their way into the mass from the intestines 
and cause suppuration. 

If the patient survives the rupture of a tubal pregnancy, and the 
placenta has not been separated to too great an extent, a secondary 
abdominal pregnancy may result. In such circumstances the usual 
symptoms of pregnancy persist, except that the woman suffers more pain 
and feels the foetal movements more acutely than usual. The pain is 
due partly to stretching and possibly to contractions of the foetal sac, 
but principally to traction upon adhesions which have formed between 

it and the various abdominal organs. 

In a small number of cases in which the primary rupture has taken 
place between the folds of the broad ligament, secondary rupture into 
the peritoneal cavity may occur at a later period, and the patient may 
bleed to death, or a secondary abdominal pregnancy may result. In 










742 


EXTRA-UTERINE PREGNANCY 


the latter event, the foetus lies within the peritoneal cavity, while the 
placenta remains partly within the tube and partly between the folds 
of the broad ligament. 

If a secondary abdominal pregnancy, or, as now and again occurs, an 
unruptured tubal pregnancy, goes on to term, false labor sets in, asso¬ 
ciated with pains similar to those occurring in the early stages of normal 
labor. These are due to uterine contractions, since the foetal sac con¬ 
tains so few muscular fibers that it cannot contract, and of course cannot 
lead to the birth of an extra-uterine child. False labor may last for 
some hours or several days, and is soon followed by the death of the 
child, although in a small number of cases the foetal movements have 
been known to persist for a considerable time after the cessation of 
the pains. 

After the death of the foetus, the placental circulation gradually 
becomes abolished, the amniotic fluid is absorbed, and the foetal sac 
retracts, so that it occupies a much smaller space than formerly. The 
abdomen consequently becomes smaller, and its change in size is soon 
noticed by the patient. After its initial shrinking, the tumor may 
remain stationary in size for a number of years, the child becoming 
mummified or converted into a lithopedion; while in rare instances 
suppurative changes may lead to its gradual discharge, or to the death 
of the patient from peritonitis. 

Combined and Multiple Pregnancies.— Parry stated in his monograph 

that 22 out of the 500 cases of tubal pregnancy collected by him were 
complicated by a coexisting intra-uterine pregnancy. He designated the 
condition as combined pregnancy. The condition occurs quite frequently, 
and has been investigated by numerous writers. Strauss in 1898 was 
able to collect only 32 cases from the literature, while Weibel in 1905 
had increased the number to 119, to which Neugebauer in 1913 added 
many more. 

In rare instances twin tubal pregnancy has been observed, both 
embryos being sometimes found in the same tube, while in other cases 
there is a foetus in each tube, both showing the same development. 
Hardouin in 1919 collected 36 examples of the former type. Arey has 
also considered the subject in detail, and makes the surprising statement 
that single ovum twins occur many times more commonly in tubal 
than in uterine pregnancy. He explains the phenomenon by supposing 
that in view oi the difficulties experienced in becoming implanted the 
rate of growth of the ovum is so retarded that two embryonic areas 
develop instead of one. Sanger, Ivrusen, and Diamant have reported 
cases of triplet tubal pregnancy. 

Repeated Tubal Pregnancy.— Parry collected 8 cases in which tubal 
pregnancy had occurred a second time in the same patient, and stated 
that Primrose in lo94 was the first to describe such a condition. With 
the increased employment of abdominal surgerv, the abnormality has 
been recognized quite frequently, the first series of cases was reported 
by Abel m 1893, while Pestalozza in 1901 collected 111 cases. In several 
instances only a few months had elapsed between the two pregnancies 
while m others they were separated by an interval of several years. 1 


DIAGNOSIS 


743 


Sampson and Smith hold that recurrence occurs so frequently that one 
is justified in removing the uterus and the non-pregnant tube at the 
time of the first operation. Smith states that patients who have once 
had a tubal pregnancy are less fertile than normal, but are exposed to 
a greatly increased probability of a second ectopic gestation. Thus, 
within five years after the primary operation 80 pregnancies occurred 
in his 144 patients, in whom subsequent conception was theoretically 
possible, and of these 23 were repeated tubal pregnancies, and Hartmann 
and Bergeret noted an almost identical proposition. 

Effects of Extra-uterine Pregnancy upon Subsequent Childbearing. 
The presence of the products of an old extra-uterine pregnancy occa¬ 
sionally gives rise to dystocia, and necessitates the performance of a 
major obstetrical operation. Thus, in the cases reported by Hugenberger, 
Schauta, and Sanger, cesarean section was performed; while Hennigsen, 
Dibot, and Brossi induced premature labor, and Stein and Cheston 
resorted to craniotomy under similar circumstances. 

As a rule, however, dystocia is not encountered, Funck-Brentano 
having collected 92 cases in which spontaneous labor occurred in patients 
still carrying the remains of a previous extra-uterine pregnancy. 

Diagnosis.—Unfortunately, the symptoms to which uninterrupted 
extra-uterine pregnancy gives rise are usually so slight that the woman 
does not consult a physician, and as a result the diagnosis is rarely 
made before rupture or abortion occurs. If, however, a patient, pre¬ 
senting the usual subjective and some of the objective symptoms of 
pregnancy, be examined, for any reason, and a unilateral tubal tumor be 
found, the diagnosis is fairly certain, especially if she has been sterile 
for a number of years or a long interval has elapsed since her last 
pregnancy. In such cases the uterus is somewhat enlarged and softened, 
while the tubal tumor is soft and doughy, and corresponds roughly in. 
size to the supposed duration of pregnancy. The first positive diagnosis 
of unruptured tubal pregnancy was made by Veit in 1883, and in this 
country by Janvrin in 1886. 

As a matter of fact, however, it usually happens that when lapa¬ 
rotomy is performed for a supposed unruptured early tubal pregnancy, a 
tumor of some other origin is found. On the other hand, the unrup¬ 
tured pregnant tube may prolapse into Douglas’s culdesac and be mis¬ 
taken for the body of a retroflexed pregnant uterus, in which event an 
attempt at its reposition may lead to rupture and occasionally to death. 

Likewise, when the foetus has died before the occurrence of rupture 
or abortion, errors in diagnosis are common, and many cases are mis¬ 
taken for incomplete uterine abortions or for tubal tumors associated 
with uterine hemorrhage. For this reason, no attempt should e\ei be 
made to empty the uterus in a case of suspected incomplete abortion, 
unless the tubes and ovaries have been previously palpated. If a caieful 
examination shows that a tumor is present on either side, the possibility 
of tubal pregnancy should be seriously considered. 

It is generally taught that the discharge of a distinct decidual cast 
from the uterus, without evidence of a foetus, is a characteristic sign of 
tubal pregnancy, especially if a tumor mass can be detected to one side 







744 


EXTRA-UTERINE PREGNANCY 


of the organ. But that such a structure now and again may be discharged 
without the existence of pregnancy of any kind was demonstrated by 
Griffiths and Dakin. Formerly, such stress was laid upon the presence 
of decidual tissue that in doubtful cases curettage was recommended 
for diagnostic purposes. My own experience has taught me that the 
presence of decidua in such circumstances usually affords strong pre¬ 
sumptive evidence, but that its absence is not equally convincing, for 
occasionally the decidua may have been cast off at an early period, and 
have been replaced by normal endometrium by the time the patient 
is examined. 

The diagnosis of tubal abortion or rupture, on the other hand, usually 
offers little difficulty, and should be made without hesitation whenever 
a patient who is believed to be pregnant has complained of pain in the 
lower part of the abdomen, and suddenly becomes faint, deathly pale, and 
sinks into a state of collapse. If the collapse becomes more profound 
and the temperature is subnormal, rupture has probably occurred. On 
the other hand, if rapid recovery ensues, the probabilities are that one 
has to deal with an abortion, and the subsequent formation of an herma- 
tocele settles the question. 

As has already been pointed out, rupture may occur at a very early 
period, even before the patient believes herself pregnant. In view of 
such a possibility, therefore, one should regard sudden collapse asso¬ 
ciated with symptoms of abdominal hemorrhage in a woman during the 
childbearing period as prima facie evidence of a ruptured tubal preg¬ 
nancy. By so doing, and operating promptly in suitable cases, a number 
of lives will be saved which otherwise would inevitably be lost. 

Very often the patient comes into the hands of the physician some 
time after she has recovered from the primary shock due to abortion or 
rupture. Under such circumstances vaginal examination will show a 
mass on one side of the uterus which is usually mistaken for pelvic 
inflammatory trouble. In such cases, Cullen has directed attention to 
the diagnostic value of a bluish discoloration of the skin about the 
umbilicus. Its presence may be regarded as positively indicating the 
existence of intraperitoneal hemorrhage, but its absence by no means 
precludes such a possibility. In a small number of cases, a fluctuant 
tumor can be felt posterior and lateral to the uterus, and when ex¬ 
ploratory puncture through the vagina reveals the presence of a dark 
bloody fluid, the diagnosis of a pelvic hematocele or a broad-ligament 
hematoma is assured. 

That the diagnosis is not always easy is shown by the fact that in 
the first 303 operations for extra-uterine pregnancy in the gynecological 
department of the Johns Hopkins Hospital, which were reported by 
Wynne, the pre-operative diagnosis was verified in only 46 per cent. 
Brady reports that in the succeeding fifty cases the percentage had 
increased to 72; but when the facility of diagnosis in the cases of 
rupture is taken into consideration, it is evident that in all other types 
errors are frequently made. 

If the child has survived the rupture, the diagnosis of secondary 
abdominal pregnancy is rarely made until false labor supervenes, unless 









TREATMENT 


745 


the physician’s attention is particularly directed to the previous history 
of the case. If, however, a careful physical examination is made, the 
uterus will be found smaller than it should be for the duration of the 
pregnancy, and displaced by the foetal sac, which makes up the greater 
part of the abdominal enlargement. Moreover, the child can be palpated 
much more readily than usual, and its movements are often very painful 
to the mother. In doubtful cases the introduction of a sound into the 
uterus is permissible. 

The diagnosis of broad-ligament pregnancy can be made by finding 
the uterus pushed to one side by a tumor intimately connected with it, 
which at the same time depresses the vaginal vault, instead of being 
high up in the abdominal cavity. 

The diagnosis of combined intra-uterine and extra-uterine pregnancy 
is rarely made until after rupture of the extra-uterine pregnancy, or 
unless the persistence of symptoms following the expulsion of the uterine 
foetus, leads to a very careful examination. The condition has never 
been diagnosed in the later months of pregnancy, although in several 
instances the presence of twins was recognized. 

After extra-uterine pregnancy has passed full term, the diagnosis 
is usually easy, and is based upon the history of pregnancy followed by 
a false labor and a gradual decrease in the size of the abdomen. Exami¬ 
nation shows the uterus to be practically normal in size, and displaced 
to a varying extent by a large tumor more or less intimately connected 
with it, in which the outlines of the child can occasionally be distin¬ 
guished. 

To recapitulate, a positive diagnosis is occasionally made before 
rupture, but in the majority of cases the condition escapes recognition 
until symptoms of collapse point to the probability of rupture or abor- 
i tion. In advanced cases careful examination will usually disclose the 
real condition of affairs, and when full term has been passed the history 
is so characteristic that mistakes should scarcely occur. 

Treatment. —As soon as an unruptured extra-uterine pregnancy is 
positively diagnosed, its immediate removal by laparotomy is urgently 
indicated, since rupture may occur at any time and the patient die from 
hemorrhage before operative aid can be obtained. The importance of 
immediate operation cannot be too strongly emphasized, and all methods 
of treatment which aim at destroying the foetus and thus terminating 
pregnancy without operation are unjustifiable. This applies not only 
to the use of electricity, but also to the injection of various poisonous 
substances into the gestation sac. 

Although Stephen Rogers, in 1867, suggested the propriety of per¬ 
forming laparotomy for the purpose of checking hemorrhage from a 
ruptured tubal pregnancy, Lawson Tait, in 1883, was the first to under¬ 
take such an operation. After he had demonstrated the ease with which 
it could be performed and the surprisingly good results obtained thereby, 
the procedure came into general use. Its beneficent results were clearly 
demonstrated by Schauta, who, after a careful study of the literature, in 
1891, found that 123 cases operated upon and 121 cases treated without 
operation presented a mortality of 5.7 and 86.9 per cent, respectively, 





746 


EXTRA-UTERINE PREGNANCY 


and at present it is not unusual to operate upon a considerable senes 
of cases without a fatality. 

For these reasons, whenever we see a possibly pregnant woman in a 
state of profound collapse, and presenting a deathly pallor of the face, 
subnormal temperature, and other symptoms of intra-abdominal hemjor- 
rhage, immediate operation is demanded, unless, indeed, her condition 
is so desperate that death is imminent. 

The abdomen should be opened rapidly, under eocain anesthesia if 
necessary. In many cases blood spurts from the abdomen as soon as.the 
peritoneum is incised, and completely obscures the field of operation. 
In these circumstances, the hand passed down alongside of the uterus 
seizes the tubal mass, which is then clamped on either side by long 
forceps. The hemorrhage having been controlled in this way, the blood 
clots are removed and the field of operation is cleaned up, after which 
the operator will be able to remove the mass and replace the clamps by 
ligatures, under the guidance of the eye, at comparative leisure. After 
the foetal sac has been taken away, it is not advisable to attempt to 
remove all the blood from the peritoneal cavity, as experience teaches 
that it can be absorbed in great part, and thus be utilized by the 
patient. 

Frequently the appendages on the opposite side may be the seat of 
chronic inflammatory lesions. Some discretion should be exercised as 
to their removal at this time, it being better to allow them to remain 
than to prolong the operation if the patient is in a very bad condition. 
At the same time, it should be remembered that their retention xyil.1 
predispose to a repetition of the accident, and on this account Sampson 
and others recommend removing the uterus along with the tubes. In 
desperate cases it is advisable to attempt to revive the patient tempo¬ 
rarily by the direct transfusion of a small quantity of blood before 
beginning the operation, and to continue the transfusion after its com¬ 
pletion. In less serious cases the subcutaneous or intravenous infusion 
of sterile salt solution should be begun while the necessary preparations 
for the operation are being made. 

In certain cases of tubal abortion, Prochownick, Martin, and others 
advocate attempting to save the tube, if possible, by opening it and 
removing the product of conception, after which it is closed by sutures. 
Although, in view of the important etiological part played by follicular 
salpingitis, such a procedure must usually be regarded as ill judged 
conservatism 

A freshly ruptured tubal pregnancy should not be attacked through 
the vagina, for the reason that the procedure is more difficult than 
a laparotomy, affords but a limited view of the field of operation, while 
there is always a possibility that it cannot be completed by the vaginal 
route. 

If the patient is not seen until the acute symptoms have subsided 
and the effused blood has become encapsulated as an hematocele, she 
should be put to bed and carefully watched, operative procedures being 
instituted only when the hematocele increases in size or symptoms indi¬ 
cative of suppuration appear. This condition, however, rarely presents 










TREATMENT 


747 


itself', and Thorn operated upon only G out of 157 such cases. When, 
however, the occasion demands it, excellent results are obtained by 
evacuating the hematocele through an incision in the vaginal fornix 
and packing the cavity with sterile gauze. Broad-ligament hematomata 
should be treated in a similar manner. 

In the later months the treatment of extra-uterine pregnancy differs 
according as the foetus is alive or dead. In very rare cases a living 
foetus may be inclosed in an unruptured tubal or ovarian sac, or lie 
between the layers of the unfolded broad ligament. More frequently, 
however, one has .0 deal with a secondary abdominal pregnancy, with 
the child lying in the peritoneal cavity and inclosed in a sac composed 
of the foetal membranes and newly formed adhesions, the placenta being 
within the tube or broadly implanted upon the floor of the pelvis. What¬ 
ever the anatomical conditions, the mother is constantly exposed to the 
possibility of sudden and acute hemorrhage so long as pregnancy con¬ 
tinues, and accordingly prompt laparotomy is the only conservative 
method of treatment. 

When the child has nearly attained the period of viability, certain 
authorities urge the propriety of deferring the operation for a few weeks 
in its interests. While such a course is inadvisable, it may be permissible 
in exceptional cases, provided the increased dangers of waiting are care¬ 
fully explained to the patient and her family and accepted by them. 

In a small number of cases the operation is comparatively easy and 
the foetal sac can be removed as readily as a large ovarian cyst. More 
frequently, however, the sac is densely adherent to surrounding organs, 
or the placental attachment is spread over a broad area, thereby markedly 
increasing the difficulty of the operation. 

Now and again, in broad-ligament pregnancies it will be found that 
the portion of the broad ligament immediately adjoining the uterus has 
not been spread apart by the growing ovum, and in such circumstances 
the entire sac may be removed without great difficulty bv ligating the 
vessels at the pelvic brim and at the uterine cornu before attempting its 
enucleation. 

As a rule, however, the complete removal of the gestation sac is by 
no means easy, and can only be effected by removing the uterus as well. 
When, as occasionally happens, it is apparent that the operation cannot 
be completed without seriously endangering the life of the patient, the 
sac should be incised, the placenta being avoided, if possible, and the 
foetus extracted. The margins of the sac are then stitched to the abdom¬ 
inal incision, the umbilical cord is cut off short, and the cavity packed 
with sterile gauze, the placenta being left in situ and afterward allowed 
to come away piecemeal. This method necessarily entails a prolonged 
convalescence, but is safer than any attempt at removal of the placenta. 
Occasionally, however, partial separation of the placenta gives rise to 
such profuse hemorrhage that its removal must be effected at any cost 
in the hope of preventing immediate death. 

The results following laparotomy in advanced cases of extra-uterine 
pregnancy with a living child have improved greatly since the intro¬ 
duction of aseptic methods. This was clearly shown by Harris, who 









748 


EXTRA-UTEIIINE PREGNANCY 


collected 27 such cases in 1887, and 145 additional cases ten years later, 
with a mortality of 93 and 31 per cent, respectively. Nevertheless, the 
operation is still one of the most dangerous which we are called upon 
to perform. 

On the other hand, if the foetus is dead the conditions are much 
more favorable, as the dangers incident to bleeding from the placental 
site are markedly diminished. For this reason, the operation should 
be deferred for six or eight weeks after foetal death in order to permit 
the obliteration of the vessels supplying the placenta, and thus render 
possible its removal without hemorrhage. In such cases, however, should 
dangerous symptoms supervene, immediate interference is indicated. In 
any event, the operation should not be deferred too long, as there is 
always a possibility that the foetal sac may become infected from the 
intestinal tract, when a fatal peritonitis may result. Lusk, in 1886, made 
an earnest plea for prompt operation in such cases, and supported his 
contention by a long array of statistics. 

In a small number of cases of advanced extra-uterine pregnancy 
operation through the vagina has been recommended. This method of 
procedure, however, has a very limited field, and laparotomy is usually 
the operation of choice. 


LITERATURE 

Abel. Zur Anatomie der Eileiterschwangerschaft nebst Bemerkungen zur Ent- 
wickelung der menschlichen Placenta. Archiv f. Gyn., 1891, xxxix, 393-436. 
Ueber wiederholte Tubengraviditat bei deselben Erau. Archiv f. Gyn., 1893, xlv, 
55-89. 

Ahlfeld. Ein Fall von Sarcoma uteri deciduo-cellulare bei Tubensc-hwangerschaft. 

Monatsschr. f. Geb. u. Gyn., 1895, i, 209-213. . 

Anning and Littlewood. A Case of Primary Ovarian Pregnancy, etc. Trans. 

London Obst. Soc., 1901, xliii; Lancet, 1901, i, 100. 

Arey. The Cause of Tubal Pregnancy and Tubal Twinning. Am. Jour. Obst. 
& Gyn., 1923, v, 163-167. 

Aschoff. Die Beziehungen der tubaren Placenta zum Tubenabort und zur Tuben- 
ruptur. Archiv f. Gyn., 1900, lx, 523-533. 

Neuere Arbeiten iiber die Anat. u. Aetiologie der Tubensehwangerschaften. Cen- 
tralbl f. allg. Path. u. path. Anat.., 1901, Nr. 11, u. 12. 

Berkeley and Bonney. Tubal Gestation: a Pathological Study. Jour. Obst. and 
Gyn. Brit. Emp., 1905, vii, 77-96. 

von Both. Rechtsseitige Tuberschwangerschaft. Ruptur im 5ten Monat. Ent- 
bindung des frei in der Bauchhohle lebenden Kindes durch Laparotomie im 
8ten Monat. Monatsschr. f. Geb. u. Gyn., 1899, 782-794. 

Brady. A Clinical Study of Extrauterine Pregnancy. Bull. Johns Hopkins Hosp., 
1923, xxxiv, 152-154. 

Breslau. Zur Aetiologie und path. Anatomie der Extrauterinschwangerschaft. 

Monatsschr. f. Geburtsk., 1863, xxi, Supplement Heft, 119-124. 

Brossi. Quoted by Sanger. 

Campbell. Abhandlung iiber die Schwangerschaft ausserhalb der Gebarmutter. 

Translated from the English, Karlsruhe and Freiburg, 1841. 

Cheston. Quoted by Funck-Brentano. 

Chiari. Betiriige zur Lehre von der Graviditas tubaria. Zeitschr. f. Heilkunde, 
1887, viii, 127-146. 



LITERATURE 


749 


Couvelaire . Note sur l’anatomie de la reflechie dans la grossesse tubaire. Comp- 
tes rendus soc. d’obst., de gyn. et de paed. de Paris, 1900, ii, 50-61. 

Quelques points de Uanatomie des grossesses tubaires en evolution, etc. Revue 
de gyn., 1902, vi, 51-84. 

Croft. An Anomalous Case of Ectopic Pregnancy, Probably Ovarian. Trans. 
London Obst. Soc., 1900, xlii, 316-323. 

Cullen. Bluish Discoloration of the Umbilicus as a Diagnostic Sign when Rup¬ 
tured Extrauterine Pregnancy Exists. Contributions to Medical and Biological 
Research. (Osier volume), 1919, I, 420-421. 

Dakin. Cast from the Uterus Having All the Characters of the Decidual Mem¬ 
brane Found in Connection with Ectopic Gestation, etc. Trans. Lond. Obst. 
Soc., 1897, xxxviii, 385-388. 

Dezeimeris. Grossesses extra-uterines. Jour, des conn, med.-chir., Paris, Dec., 
1836. 

Diamant. Ein Fall von Drillingsschwangerschaft in demselben Eileiter. Zen- 
tralbl. f. Gyn., 1914, 128-129. 

Dibot. Quoted by Sanger. Monatsschr. f. Geb. u. Gyn., 1895, i, 21-28. 

Doderlein u. Herrgott. A New Type of Ectopic Gestation. Pregnancy in an 
Adenomyoma Uteri. Surg. Gyn. and Obst., 1913, xvi, 14-19. 

Duhrssen. Ueber operative Behandlung, insbesondere die vaginale Coeliotomie 
bei Tubarschwangerschaft, etc., nebst Bemerkungen zur Aetiologie der Tubar- 
schwangerschaft und Beschreibung eines Tubenpolypen. Archiv f. Gyn., 1897, 
liv, 207-323. 

Fehling. Die Bedeutung der Tubenruptur und des Tubaraborts fiir Verlauf, 
Prognose und Therapie der Tubarschwangerschaft. Zeitschr. f. Geb. u. Gyn., 
1898, xxxviii, 67-100. 

Franz. Ueber Einbettung u. Wachstum des Eies in Eierstock. Beitrage zur 
Geb. u. Gyn., 1902, vi, 70-81. 

Freund. Beitrage zur Anatomie der ausgetragenen Extrauteringraviditat. 
Beitrage z. Geb. u. Gyn., 1903, vii, 104-137. 

Funck-Brentano. Des grossesses uterines survenant apres la grossesse extra- 
uterine. These de Paris, 1898. 

Futh. Ueber die Einbettung des Eies in der Tube. Archiv f. Gyn., 1901, lxiii, 
97-158. 

Ueber Ovarialschwangerschaft. Beitrage zur Geb. u. Gyn., 1902, vi, 314-331. 

Gottschalk. Ein Praparat von Ovarialschwangerschaft aus der 3-4. Woche der 
Graviditat. Zentralbl. f. Gyn., 1886, x, 727. 

Ein Lithokelyphopadion, das gleichzeitig als Fall von reiner Eierstocks- 
schwangerschaft sehr bemerkenswerth ist. Verhandlungen der deutschen Ges. 
f. Gyn., 1893, 304-305. 

Griffiths. Note on the Importance of a Decidual Cast as Evidence of Extra- 
uterine Gestation. Trans. London Obst. Soc., 1894, xxxvi, 335-340. 

Gubb. The Placenta in Ectopic Gestation and Its Growth after the Death of the 
Foetus. Med. Press and Circular, 1894, lvii, 326. 

Gurgui. Die Ovarialschwangerschaft vom path. anat. Standpunkte. Stuttgart, 

1880. 

Hardouin. Grossesses extrauterines g&nellaires unitubaires. Archives mens, de 
gyn. et d’obst., 1919, viii, 331-341. 

Harris. Operation of Primary Laparotomy in Cases of Extra-uterine Pregnancy. 
Amer. Jour. Obst., 1887, xx, 1154-1167. 

Weitere Fortschritte der Entbindung ektopischer lebensfahiger Friichte durch 
Koeliotomie. Monatsschr. f. Geb. u. Gvn., 1897, vi, 137-156. 

Hart. On the Alleged Growth of the Placenta in Extra-uterine Gestation After 
the Death of the Foetus. Amer. Jour, of Obst., 1892, xxv, 721-735. 


750 


EXTRA-UTERINE PREGNANCY 


Hartmann and Bergeret. 146 cas consecutifs de grossesse extrauterine. Annales 
de gyn. et d’obst., 1919, xiii, 321-345. 

Hecker. Beitrage zur Lehre von der Schwangerschaft ausserhalb der Gebiir- 
mutterhohle. Monatsschr. f. Geburtsk., 1859, xiii, 81-123. 

Heinsius. Ueber tubare Einbettung des menschlichen Eies. Monatsschr. f. Geb. 
u. Gyn., 1902, xv, 315-322. 

Hennigsen. Abdoniinalschwangerschaft bei einer Sechstgebarenden. Archiv f. 
Gyn., 1870, i, 335-340. 

Henning. Die Krankheiten der Eileiter und die Tubenschwangerschaft. Stutt¬ 
gart, 1876. 

Henrotin et Herzog. Anomalies du canal de Miiller comme cause des gros- 
sesses ectopiques. Revue de gyn., 1898, 633-649. 

Hirst and Knipe. Primary Implantation of an Ovum on the Pelvic Peritoneum. 
Surg. Gyn. and Obst., 1908, vii, 156-159. 

Hoehne. Die Hypoplasie der Tuben in ihrer Beziehung zur Extrauteringraviditat. 
Zeitschr. f. Geb. u. Gyn., 1908, lxiii, 106-123. 

Die Aetiologie der Graviditas extrauterina. Archiv f. Gyn., 1917, cvii, 73-108. 

Hofmeier. Zur Kenntniss dem normalen Uterusschleimhaut. Zentralbl. f. Gyn., 
1893, xvii, 764-766. 

Hugenberger. Bericht aus dem Hebammen-Institut in Moskau. St. Petersburg, 
1863, 122. 

Jacquin. La grossesse abdominale primitive. Obst. et Gyn., 1922, v, 492-512. 

Janvrin. A Case of Tubal Pregnancy of Unusual Interest. Trans. Amer. Gyn. 
Soc., 1886, xi, 471-484. 

Kermauner. Beitrage zur Anatomie der Tubenschwangerschaft. Berlin, 1904. 

Kouwer. Fall von Schwangerschaft im Graaf ’schen Follikel. Zentralbl. f. Gyn., 
1897, xxi, 1426. 

Kreisch. Beitrag zur Anatomie und Pathologie der Tubargraviditat. Monats¬ 
schr. f. Geb. u. Gyn., 1899, ix, 794-812. 

Kuchenmeister. Ueber Lithopadion. Archiv. f. Gyn., 1881, xvii, 153-359. 

Kuhne. Beitrag zur Anatomie der Tubenschwangerschaft. Marburg, 1899. 

Kustner. Ueber Extrauterinschwangerschaft. Volkmann’s Sammlung klin. Vor- 
trage, N. F., 1899, Nr. 244-245. 

Landau und Rheinstein. Beitrage zur pathologischen Anatomie der Tube. 
Archiv f. Gyn., 1891, xxxix, 273-290. 

Leopold. Zur Lehre von der Graviditas interstitialis. Archiv f. Gyn., 1878, xiii, 
355-365. 

Ovarialschwangerschaft mit Lithopadionbildung von 35-jahriger Dauer. Archiv 
f. Gyn., 1882, xix, 210-218. 

Beitrage zur Graviditas extrauterina. Archiv f. Gyn., 1899, lviii, 525-565, and 
lix, 557-594. 

Lequeux. A propos de quelques cas de grossesse interstitielle. L ’obst., 1911, iv, 
493-524. 

Lichtenstein. Basiotrope Placentation, etc. Zentralbl. f. Gyn., 1920, 657-673. 

Lockyear. Two Cases of Primary Ovarian Pregnancy, etc. Proc. Royal Soc. of 
Med., 1917, x, 158-182. 

Ludwig. Eierstocksschwangerschaft neben normaler uteriner Schwangerschaft, 
etc. Wiener klin. Wochenschr., 1896, ix, 600-604. 

Lusk. The Desirability of the Early Performance of Laparotomy in Cases of 
Abdominal Pregnancy. British Med. Jour., 1886, ii, 1083-1090. 

Mall. The Cause of Tubal Pregnancy and the Fate of the Enclosed Ovum. Surg. 
Gyn. and Obst., 1915, xxi, 289-298. 

On the Fate of the Human Embryo in Tubal Pregnancy. Publication 221, 
Carnegie Institution, 1915, p. 104. 


LITERATURE 


751 


Mall and CULLEN. An Ovarian Pregnancy Located in the Graafian Follicle. 
Surg. Gyn. and Obst., 1913, xvii, 698-703. 

Mandl. Ueber den feineren Bau der Eileiter wahrend und ausserhalb der 
Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1897, V. Erganzungsheft, 
130-139. 

Ueber die Ricktung der Flimmerbewegung im menschlichen Uterus. Zentralbl. 
f. Gyn., 1898, xxii, 323-328. 

Mandl und Schmidt. Beitrage zur Aetiologie und path. Anatomie der Eileiter- 
schwangerschaften. Archiv f. Gyn., 1898, lvi, 401-487. 

Martin. Zur Kenntniss der Tubarschwangerschaft. Monatsschr. f. Geb. u. Gyn., 
1897, v, 1-7 and 244-246. 

Mayer. Kritik der Extrauterinschwangerschaft, etc. Giessen, 1845. 

Mendes de Leon et Holleman. De la grossesse ovarienne. Revue de gvn., 1902, 
vi, 337-400. 

Meyer. Hydatiform degeneration in tubal pregnancy. Surg. Gyn. & Obst., 1919, 
xxviii, 293-302. 

Meyer and Wynne. Some Aspects of Ovarian Pregnancy. Bull. Johns Hopkins 
Hosp., 1919, xxx, 92-98. 

Mikolitsch. Ueber Ovarialgraviditat. Zeitschr. f. Geb. u. Gyn., 1903, xlix, 508- 
522. 

Zur Aetiologie der Tubenschwangerschaft. Zeitschr. f. Geb. u. Gyn., 1903, 
xlix, 42-62. 

Moericke. Zur Aetiologie der Tubengraviditat. Sammlung zwangloser Abhand- 
lungen aus dem Gebiete der Frauenkeilkunde u. Geb., 1900, Bd. iii, H. 4 u. 5. 

Neugebauer. Eine neue Se.rie von 73 Fallen isochroner heterotyper Zwillings- 
schwangerschaft. Gyn. Rundschau, 1913, vii, 809-831. 

Oliver. Ovarian Pregnancy. Lancet, 1896, ii, 241. 

Opitz. Ueber die Ursachen der Ansiedlung des Eies ini Eileiter. Zeitschr. f. 
Geb. u. Gyn., 1902, xlviii, 1-39. 

Otto. Ueber Tubenschwangerschaft mit Beriieksichtigung eines Falles von Gravi¬ 
ditas tubaria molaris hydatidosa. E>. I., Greifswald, 1871. 

Parry. Extra-uterine Pregnancy. London, 1876. 

Pestalozza. Sulla gravidanza tubarica recidivante. Annala di ost. e gin., 1901, 
No. 1. 

Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. 

Pfannenstiel. Extrauterine Graviditat. Yerh. d. deutschen Gesellschaft f. Gyn., 
1903, x, 194-199. 

Pinard. Nouveaux documents pour servir a l'histoire de la grossesse extra- 
uterine. Annales de gyn. et d’obst., 1892, xxxviii, 1-11; 99-118; 181-188. 

Prochownick. Ein Beitrag zur Mekanik des Tubenaborts. Festschrift der Ges. 
f. Geb. u. Gyn. in Berlin, Wien, 1894, 266-295. 

Zur Mekanik des Tubenaborts. Archiv f. Gyn., 1895, xlix, 177-241. 

Risel. Zur Kenntniss des primaren Chorioepithelioms der Tube. Zeitschr. f. 
Geb. u. Gyn., 1905, lvi, 154-189. 

Robson. Primary Ovarian Gestation. Trans. London Obst. Soc., 1902, xliv, 215- 

221 . 

Rogers. Extra-uterine Fetation and Gestation, etc. Philadelphia, 1867. 

Rosenthal. Ein Fall intramuraler Schwangerschaft. Zentralbl. f. Gyn., 1896, 
xx, 1297-1305. 

Runge. Beitrag zur Aetiologie der Extrauteringraviditat. Archiv f. Gyn., 1903, 
lxx, 690-722. 

Beitrag zur Anatomie der Tubergraviditat. Archiv f. Gyn., 1904, lxvi, 652-674. 

Sampson. The Influence of Ectopic Pregnancy on the Uterus. Trans. Am. Gyn. 
Soc., 1913, xxxviii, 121-166. 







752 


EXTRA-UTERINE PREGNANCY 


Sanger. Ueber einen Fall von ektopischer Drillingsschwangersehaft. Zentralbl. 
f. Gyn., 1893, xvii, 148. 

Ueber solitare Hamatocele und deren Organisation. Verh. der deutschen Ges. f. 
Gyn., 1893, 281-302. 

Conception durch ein accessorisches Tubenostium. Kaiserschnitt bedingt durch 
friihere ektopische Schwangerschaft. Monatsschr. f. Gob. u. Gyn., 1895, i, 
21-28. 

Schauta. Beitrage zur Kasuistik, Prognose und Therapie der extrauterinen 
Schwangerschaft. Prag, 1891. 

Tubarschwangerschaft mit HaematoKimole. Zentralbl. f. Gyn., 1903, xxvii, 
1402-1403. 

Schumann. Extra-uterine Pregnancy. Appleton, 1921. 

Sippel. Ueber aussere Ueberwanderung des Eies. Zentralbl. f. Gyn., 1901, xxv, 
289-296. 

Smith. Final Results in One Hunderd and Ninety-two Patients Operated upon 
for Ectopic Pregnancy. Surg. Gyn. and Obst., 1914, xviii, 684-695. 

Spiegelberg. Eine ausgetragene Tubenschwangerschaft. Archiv f. Gyn., 1870, i, 
406-414. 

Zur Kasuistik der Ovarialschwangerschaft. Archiv f. Gyn., 1878, xiii, 73-79. 

Stein. Quoted by Funck-Brentano. 

Strauss. Tubargraviditat bei gleichzeitiger intrauteriner Schwangerschaft. 
Zeitsclir. f. Geb. u. Gyn., 1900, xliv, 26-38. 

Sutton. The Purvis Oration on Abdominal Pregnancy in 'Women, Cats, Dogs, and 
Rabbits. Lancet, 1904, ii, 1625. 

Tainturier. Etiologie de la grossesse ectopique. These de Paris, 1895. 

Tait. Lectures on Ectopic Pregnancy and Pelvic Haematocele. Birmingham, 1888. 

Taylor. Extra-uterine Pregnancy. A Clinical and Operative Study. London, 
1899, 205. 

Teuffel. Hydramnion bei Extrauterinschwangerschaft. Archiv f. Gyn., 1884, 
xxii, 57-64. 

Thompson. Ovarian Pregnancy, with Report of a Case. American Gynecology, 
1902, i, 1-15. 

Thorn. Ueber Beckenhamatome. Yolkmann’s Sammlung klin. Yortrage, N. F., 
Nr. 119 u. 120. 

Toth. Beitrage zur Frage der ektopischen Schwangerschaft. Archiv f. Gyn., 
1896, li, 410-482. 

Tussenbroek. Un cas de grossesse ovarienne (Grossesse dans un follicule de 
Graaf). Annales de gyn. et d ’obst., 1899, lii, 537-573. 

Yeit. Die Eileitersehwangerschaft. Stuttgart, 1884. 

Ueber Deportation der Chorionzotten. Zeitschr. f. Geb. u. Gyn., 1901, 466-504. 

Die Yerschleppung der Chorionzotten. Wiesbaden, 1905. 

Yelpeau. Traite complet de 1’art des accouchements. Paris, 1835, t. i, 214. 

A t oigt. Schwangerschaft auf der Fimbria ovarica. Monatsschr. f. Geb. u. Gyn., 
1898, viii, 222-232. 

Walker. Ein Fall von primarer Abdominalschwangerschaft. Archiv. f. Gyn., 
1919, cxi, 342-369. 

Walthard. Ueber ein junges inenschliches Ei, etc. Zeitschr. f. Geb. u. Gyn., 
1911, lxix, 553-581. 

Webster. Ectopic Pregnancy. Edinburgh and London, 1895. 

Study of a Specimen of Ovarian Pregnancy. Am. Jour. Obst., 1904, i, 28-44. 

A Second Specimen of Ovarian Pregnancy. Trans. Am. Gyn. Soc., 1907, xxxii, 

122 . 

Weibel. Ueber gleichzeitige Extra- und Intrauteringraviditat. Monatsschr. f. 
Geb. u. Gyn., 1905, xxii, 739-771. 


LITERATURE 


753 


Wenzel. Blasenmole im Eileiter. Alte Erfahrungen im Lichte der neuen Zeit, 
Wiesbaden, 1893, 85-89. 

Werth. Beitrage zur Anatomie und zur operativen Behandlung der Extrauterin¬ 
schwangerschaft. Stuttgart, 1887. 

Die Extrauterinschwangerschaft. WinckeUs Handbuch der Geburtshiilfe, 1904, 

ii, 2, 655-1018. 

Wertheim. Haematommole bei Tubenschwangerscliaft. Zentralbl. f. Gyn., 1903, 
xxvii, 1403. 

Williams. Contribution to the Normal and Pathological Histology of the Fal¬ 
lopian Tubes. Amer. Jour. Med. Sciences, October, 1891. 

Wyder. Beitrage zur Lelire von der Extrauterinschwangerschaft und dem Orte 
des Zueammentreffens von Ovulum und Spermatozoen. Arcliiv f. Gyn., 1886, 
xxviii, 325-407. 

Wynne. Ectopic Pregnancy. Bull. Johns Hopkins Hosp., 1919, xxx, 15-25. 

Interstitial Pregnancy. Bull. Johns Hopkins Hosp., 1918, xxix, 29-35. 

Young. The Anatomy of the Pregnant Tube. Edinburgh Med. Jour., 1909, N. S. 

iii, 118-150. 

Reproduction in the Human Female. Edinburgh and London, 1911. 

Zedel. Zur Anatomie der schwangeren Tube mit besonderer Beriicksichtigung 
des Baues der tubaren Placenta. Zeitschr. f. Geb. u. Gyn., 1893, xxvi, 78-143. 
Zweifel. Ueber Extrauteringraviditat und retrouterine Hamatome. Archiv f. 
Gyn., 1891, xli, 1-61. 


SECTION VII 


PATHOLOGY OF LABOR 


CHAPTER XXXI 

DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES 

Dystocia or difficult labor may be due to various causes, and is most 
commonly encountered in the following groups of cases: (1) Those in 
which the expulsive forces are subnormal and are not sufficiently strong 
to overcome the natural resistance offered to the birth of the child by 
the bony canal and the maternal soft parts. (2) Those in which, 
although the expulsive forces may be of normal strength, abnormalities 
in the structure or character of the birth canal offer a serious me¬ 
chanical obstacle to the descent of the presenting part. (3) Those in 
which the foetus, on account of faulty presentation or excessive develop¬ 
ment, cannot be extruded by the vis a ter go. (4) Those cases in which 
accidental complications, such as eclampsia, hemorrhage, or rupture of 
the uterus, lead to various irregularities which interfere with the normal 
progress of labor. 

The expulsion of the foetus is brought about by the contractions of 
the uterus, reenforced during the second stage of labor by the action of 
the muscles of the abdominal wall. Either of these factors may be 
lacking in force or intensity, while occasionally they may be abnormally 
strong. 

Unfortunately, there is no absolute standard by which the character 
of the labor pains can be gauged. Thus, in an exceptional primiparous 
woman a rapid and happy termination of labor may follow a few rela¬ 
tively slight pains, which in the majority of normal primiparae would 
prove quite inadequate to bring about the desired result. Clinically 
the efficiency of the uterine contractions may be measured by their 
effect upon the course and duration of labor, provided there is no 
serious mechanical obstacle to be overcome, so that, other things being 
equal, prolonged or precipitate labor occurs as a result of abnormalities 
in their frequency and intensity. 

Prolonged Labor. —Normally, in the early stages of labor, the uterine 
contractions recur at infrequent intervals, and gradually increase in 
frequency, intensity, and duration as its termination is approached. 
Moreover, a proper alternation between the contraction and relaxation 
of the uterus is a very important requisite for the successful accomplish¬ 
ment of delivery. 

Anomalies are often noted in the first stage of labor. In many 

754 


PROLONGED LABOR 


755 


instances the pains recur at long intervals and are so feeble in character 
that dilatation of the cervix is unduly prolonged, with the result that 
labor, instead of being terminated within the usual period, may drag 
on for days. If the membranes are unruptured and the patient is in 
good condition, the delay may be regarded with equanimity, since in the 
great majority of instances the pains eventually become stronger and 
more frequent, when the birth of the child is effected without interfer¬ 
ence. For this reason, in the absence of symptoms indicative of danger 
to the mother or child, mere prolongation of labor is not necessarily 
serious; as it may happen that in a labor lasting 48 hours or longer 
the patient may suffer less and have actually fewer uterine contractions 
than another woman in whom the process is completed within the usual 
period. In such cases, the obstetrician should not interfere hastily, 
but should encourage the patient to bear her suffering patiently by a 
plain statement of the facts of the case, and the assurance that a favor¬ 
able outcome may be expected, not only for her but also for the child. 

Again, labor sometimes begins in a perfectly typical manner and 
gives every promise of an ordinarily speedy termination, and yet after 
a certain lapse of time, without any appreciable cause, the pains become 
less frequent and less intense, although giving rise to quite as much or 
even more suffering than previously. At the same time, the cervix, 
which was becoming obliterated and dilated in a satisfactory manner, 
ceases to make further progress, and labor apparently comes to a stand¬ 
still. The former condition is attributed to primary, and the latter to 
secondary, inertia uteri. 

In other instances, the contractions, although recurring at frequent 
intervals, are very painful and cramplike in character, but exert very 
little influence upon the dilatation of the cervix. As a result, oblitera¬ 
tion of its canal is brought about very slowly, and the external os 
undergoes but little change. As a rule, such conditions do not give rise 
to serious complications, since under appropriate treatment the pains 
usually assume a more normal character, after which the termination of 
labor is speedily accomplished. 

In all of these conditions the prolongation of labor is commonly 
attributed to the imperfect dilatation of the cervix, which is supposed 
to be due to an abnormal rigidity of its tissues. Ordinarily, however, 
the converse is true, and the tardy dilatation is the direct result of faulty 
uterine contractions. That this interpretation is correct is shown by 
the fact that the appearance of satisfactory contractions is promptly 
followed by rapid dilatation of the cervix and a happy termination of 
labor. On the other hand, however, especially in elderly primiparae, 
who have passed their thirtieth year, excessive rigidity of the cervix and 
its consequent tardy and imperfect dilatation may be the essential factor 
in the production of the dystocia, especially when a further complication 
has been introduced by the premature rupture of the membranes. 

This accident may occur before the onset of uterine contractions, 
and hours, and occasionally days, may elapse between the escape of the 
amniotic fluid and the onset of uterine contractions. Consequently, it 
is unwise in such cases to express a definite opinion as to when labor 





750 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES 


will set in, but one is usually safe in predicting that contractions will 
begin within 24 hours. In other cases the membranes may rupture 
early in labor, and before any great degree of cervical dilatation has 
occurred. In either event, we have to deal with what is designated as 
“dry labor,” which is usually unduly prolonged and very painful. The 
delay is due in great part to the absence of the hydrostatic action of 
the bag of waters, in consequence of which the changes in the cervix 
must be brought about almost entirely by the direct pressure of the 
presenting part, which acts as a dilating wedge of imperfect shape and 
consistency. According to Basset and Demelin this complication occurs 
in about every tenth labor, and is less serious in multiparae than in 
primiparae, on account of the decreased resistance of the cervix in the 
former. 

Premature rupture of the membranes not only leads to prolongation 
of labor, but also increases the probability of intrapartum infection 
even though vaginal examinations have not been made, as bacteria from 
the vulva may multiply in the capillary layer of fluid in the vagina 
and readily gain access to the open amniotic sac. Fortunately, 
such infections, which occur in about every fifth dry labor, are 
usually not serious, and all signs of them disappear within 24 hours 
after delivery, but occasionally they may lead to puerperal infection of 
the patient, and Warnekros has demonstrated that bacteria may be found 
in the maternal blood before the completion of delivery. Even when 
the mother escapes infection, the condition is not devoid of danger, as 
it has long been known that in such cases the child, which is born alive, 
may succumb a few days later. Hellendahl and others thought that 
it became infected by swallowing the contaminated amniotic fluid, but 
Slemons showed that in a certain proportion of cases the bacteria make 
their way through the amnion covering the foetal surface of the placenta, 
and, after invading the large vessels which lie just beneath it, gain 
access to the foetal circulation and give rise to general septicemia or 
to peritonitis. Slemons designated the process as placental bacteremia, 
and held that it plays a considerable part in the production of late foetal 
mortality. 

Not uncommonly obliteration of the cervical canal takes place with¬ 
out difficulty, while the external os alone appears to offer the obstacle to 
dilatation. In such cases its margins are often extremely thin and sharp, 
and during a contraction may not exceed a sheet of paper in thickness. 
On the other hand, especially when labor is unduly prolonged, they may 
become thick and edematous. 

In the absence of any mechanical obstacle, prolongation of the second 
stage of labor is rarely due to abnormalities in the uterine contractions, 
but rather to deficient action of the abdominal muscles. In primiparous 
women, especially, the tardy labor is often ascribed to the resistance 
offered by a rigid perineum and a small vaginal outlet, but in the ma¬ 
jority of cases this is only apparent, the delay being really due to an 
insufficient vis a tergo, or to the head, which was descending with the 
occiput obliquely posterior, undergoing only partial rotation and being 
arrested in the deep transverse position. 






PROLONGED LABOR 


757 


Etiology .—Uterine insufficiency is usually attributed to one of three 
causes: faulty development or diseased conditions of the uterine muscu¬ 
lature, anomalies in its innervation, or mechanical interference with its 
contraction. The first factor is the one most frequently concerned in 
the causation of tardy labor, and is especially likely to be associated 
with imperfect general development, being most frequently observed in 
patients possessing justominor pelves, but only very rarely in sufferers 
from rachitic deformities. It should, however, he remembered that 
faulty development of the uterine musculature is occasionally noted in 
apparently normal women, and is relatively common in large, thick set, 
and corpulent individuals. 

Sometimes the faulty action of the uterine muscle is attributable to 
a loss of tonicity incident to excessive distention, and is therefore met 
with in women who have passed through a number of pregnancies in 
rapid succession, or in whom the uterus lias been subjected to acute 
distention, as in multiple pregnancy and hydramnios. Much less com¬ 
monly the defect is due to general weakness following exhausting diseases, 
but that this is rarely responsible is shown by the common observation 
that the pains are usually efficient even in patients suffering from 
advanced stages of tuberculosis. 

We are almost entirely ignorant concerning the nervous control of 
the uterine contractions, and consequently direct proof of the existence 
of abnormalities in the innervation of the uterine musculature cannot 
be adduced; nevertheless, clinical observation affords strong presumptive 
evidence in favor of this view, or at least indicates clearly that ex¬ 
traneous causes may interfere reflexly with the activity of the uterus. 
Thus, it is a matter of common experience that the entrance of the 
obstetrician into the lying-in chamber is frequently followed by a tem¬ 
porary cessation of the labor pains. Moreover, extreme nervousness, 
profound mental emotions, or excruciating pain may have a similar 
effect. In such cases, the severe pain is often due to the irregular action 
of the uterus, which in turn, by acting reflexly, interferes still further 
with its function, thus giving rise to a vicious circle. That reflex 
nervous influences are frequently responsible is shown by the fact that 
the administration of a sedative may be followed by a return of satis¬ 
factory contractions. 

That the action of the uterus is occasionally influenced by mechanical 
conditions is shown by the frequent association of unsatisfactory con¬ 
tractions with the presence of multiple myomata in the uterine wall. 
Much the same effect is exerted when the organ sags markedly forward 
in a pendulous abdomen. Old adhesions about the uterus and appen¬ 
dages and fresh inflammatory areas in the same location may act in 
a similar manner. 

In the second stage defective abdominal contractions may be due 
to a number of causes. The insufficiency may result from faulty develop¬ 
ment of the muscles themselves—more frequently it is due to a loss of 
muscular tone following excessive distention, so that it is much more 
common in multiparous than in primiparous women. In many instances 
the insufficiency is only apparent, and is due to the fact that for fear of 




758 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES 


increased pain the patient is unwilling to bring her abdominal muscles 
into full play, and accordingly makes voluntary efforts to restrain them. 
For this reason the obstetrician is sometimes obliged to terminate labor 
by means of low forceps, although he feels sure that a few minutes’ 
effective use of the abdominal muscles would lead to spontaneous delivery. 
In many such cases the induction of anesthesia is attended by happy 
results, since it dulls the sensation of pain sufficiently to enable the 
patient to bring her abdominal muscles into action. 

Treatment of Prolonged Labor .—Active treatment is rarely demanded 
when the tardy labor is the result of infrequent pains of slight intensity, 
as they gradually become more severe and eventually bring about a 
spontaneous delivery. It is highly important that the physician should 
remember that the gravity of a case of labor is not measured by its 
duration alone, and that interference is not indicated unless objective 
signs of exhaustion or infection, or danger to the child, become manifest. 
Should the labor last for several days it is important that the moral 
courage of the patient be maintained, and that she should sleep well 
at night. Consequently, the administration of hypnotics, or even of 
morphin hypodermically, is indicated. 

On the other hand, when the pains follow one another in rapid 
succession without exerting any appreciable effect upon the dilatation 
of the cervix, but are inefficient and cramplike, excellent results often 
follow the administration of a hypodermic injection of morphin (grain 
14 ), combined with the sulphate of atropin (grain 1-150) ; or of a rectal 
injection containing 30 grains of chloral hydrate in 4 ounces of warm 
milk, and repeated, if necessary, in one hour. 

When the dystocia is due to secondary uterine inertia the problem is 
more difficult; though, as a rule, if the patient can obtain several hours 
of sound sleep, more satisfactory pains will appear when she wakens. 
For this reason the use of a hypnotic is often indicated. In other cases, 
the administration of 15 grains of quinin sulphate, in solution or in 
freshly prepared capsules, or the same amount of the hydrochlorate 
hypodermically, is promptly followed by a marked increase in the fre¬ 
quency and efficiency of the uterine contractions. If, however, the uterus 
does not respond to that amount of the drug, its further administration 
may be regarded as useless. As I have had no experience with the 
intravenous administration of a solution of glucose, which has been 
enthusiastically recommended by Muller, I cannot express an opinion 
as to its value. 

Following the discovery by Dale that the administration of an ex¬ 
tract of the infundibular portion of the hypophysis stimulated the 
uterine contractions, Hofbauer, in 1911, advocated its employment in 
uterine inertia. Since then an immense literature has accumulated upon 
the subject, and numerous preparations have been put upon the market 
—such as pituitrin. pituitary liquid, hypophysin, pituglandol, etc. Fol¬ 
lowing the contribution of Parisot and Spire, it has become established 
that the hypodermic administration of 1 cubic centimeter of any efficient 
preparation promptly results in a great increase in the force of the 
uterine contractions. Many writers have therefore recommended its use 


1: 








PROLONGED LABOR 


759 


in the class of cases under discussion, but, as will be indicated below, 
I consider its administration highly reprehensible during the first stage 
of labor. 

Ergot was formerly used with a free hand in this condition, but at 
present is employed only by ignorant midwives. It is true that its 
administration may be followed by an increase in the intensity of the 
uterine contractions, but they soon lose their normal characteristics and 
become tetanic. As a result the uterus is liable to remain firmly con¬ 
tracted upon its contents, and, no longer alternating between contraction 
and relaxation, loses its expulsive power, so that the final action of 
the drug is to defeat the very purpose for which it was given. Moreover, 
if a mechanical obstacle exists, the use of ergot may lead to so pro¬ 
nounced an overstretching of the lower uterine segment that rupture 
occurs. Accordingly, it should never be employed for its oxytocic prop¬ 
erties, but should be used only as a means for controlling uterine 
hemorrhage after the expulsion of the placenta. 

As has already been pointed out, abnormalities in the contractions of 
the uterus are usually associated with imperfect dilatation of the cervix, 
and in elderly primiparae, and occasionally in younger women who have 
suffered from inflammatory conditions about the cervix, rigidity of the 
tissues can sometimes be invoked as its underlying cause. In these 
circumstances, as well as in many cases of dry labor, the administration 
of a sedative is followed by satisfactory results. The use of an anes¬ 
thetic, although it sometimes leads to satisfactory dilatation of the 
cervix, is generally inadvisable, inasmuch as the patient, having once 
experienced its soothing effect, refuses to dispense with it, so that the 
obstetrician will often be obliged to continue its employment, with the 
result that the uterine contractions become less frequent and efficient, 
and render operative interference necessary. Occasionally a hot full bath 
is attended by satisfactory results. 

Operative interference, however, should be undertaken only in the 
presence of objective symptoms, indicative of profound exhaustion or 
infection on the part of the mother, or of actual danger to the child. 
In my experience, there are few obstetrical conditions which require 
greater nicety of judgment as to the necessity for interference and choice 
of procedure; for, should the result be unsatisfactory, one is usually 
inclined to regret his decision and to wish that he had delayed inter¬ 
ference or had chosen some other procedure. Generally speaking, if 


there is no disproportion between the size of the child and the birth 
canal, and the cervical canal is obliterated, and resistance is offered 
only by an external os, presenting thin margins and a diameter of 
five or more centimeters, excellent results may be obtained by completing 
the dilatation by Harris’ manual method, and then effecting delivery 
by version or forceps according to the exigencies of the case. This 
procedure, however, should be resorted to only in the presence of some 
pressing indication, and should not be attempted merely for the sake 
of shortening the labor; for, even when practiced under the relatively 
favorable conditions just mentioned, it frequently results in extensive 
laceration of the cervix, which requires immediate repair. That such 






760 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES 


a warning is necessary is shown by the fact that each year I see in 
consultation several women who die from hemorrhage or infection fol¬ 
lowing deep cervical tears, which have resulted from unnecessary or too 
hasty interference. 

If the cervical canal has not become obliterated, manual dilatation 
should not be considered, but a moderate sized Champetier de Hibes 
bag should be introduced into the uterus. This usually acts as an 
efficient irritant, and brings about satisfactory contractions with resulting 
dilatation in the course of a few hours. If, however, the indication 
for delivery is urgent, vaginal hysterotomy may be employed with ad¬ 
vantage, as recommended by Seitz. In all such conditions, every detail 
of aseptic technic should be scrupulously observed and no attempt made 
to deliver the child until all obstacle on the part of the cervix has been 
overcome. Cesarean section should not be thought of in such cases, as 
so much time has elapsed since the onset of labor that, while the opera¬ 
tion may save the life of the child, it will expose the patient to an 
unjustifiable risk. 

Tardy labor, due to the prolongation of the second stage, whether 
resulting from deficient uterine or abdominal action or from unusual 
resistance on the part of the perineum, is best treated by the application 
of forceps, except when the dystocia is attributable to disproportion 
between the size of the child and the pelvis. 

Following the discovery of the oxytocic properties of pituitary extract 
a great revolution has occurred in the treatment of this type of prolonged 
labor, and my experience has shown that the judicious administration 
of pituitrin will do away with the necessity for the application of low 
forceps in from one-third to one-half of the cases in which it was 
formerly employed. Notwithstanding this apparently enthusiastic state¬ 
ment, I consider that great caution should be exercised in the use of 
the drug, as its injudicious employment may place the life of both 
mother and child in jeopardy. Furthermore, I feel that the claims 
made by several manufacturing chemists concerning its harmlessness 
are incorrect and reprehensible, and are calculated to lead inexperienced 
practitioners into therapeutic excesses to the great detriment of their 
patients. 

As a result of my experience, I would state categorically that the 
use of pituitrin is absolutely contra-indicated in the presence of me¬ 
chanical disproportion or before the cervix has become fully dilated, and, 
furthermore, that in primiparae it is generally inadvisable until the 
presenting part has reached the pelvic floor. Its chief indications are 
twofold—First, in multiparae suffering from uterine inertia, in whom 
labor has come to a standstill with the cervix fully dilated and the 
head lying below the ischial spines; and, secondly, in primiparae, when 
the head has become arrested at the vaginal outlet, and it seems that 
only a few strong expulsive efforts are needed for its extrusion. 

In many such cases, within three minutes after the hypodermic 
administration of one-half cubic centimeter of a reliable preparation, 
the uterine contractions undergo a veritable revolution, and the pains, 
which were pre\iously sluggish and far apart, become strong, regular and 






PRECIPITATE LABOR 


761 


efficient, with the result that labor is promptly terminated. The action 
of pituitrin is relatively evanescent, and usually becomes exhausted 
within 15 or 20 minutes; consequently, if a result is not obtained within 
that period none can be expected, and delivery should be terminated by 
low forceps, instead of repeating the dose. 

Occasionally, however, even when the above conditions are fulfilled, 
the results are not so happy, and the uterus, instead of being stimu¬ 
lated to regular activity, passes into a condition of tetanic contraction. 
In several instances this became so alarming that I felt compelled to 
place the patients under the full anesthetic action of chloroform. If 




this can occur during the latter part of the second stage in an otherwise 
normal labor, it is apparent what may happen if the head is arrested 
at the superior strait as the result of a contracted pelvis or an abnormal 
presentation, or when the cervix is only partially dilated. That the 
danger of rupture of the uterus is not hypothetical, is shown by the 
fact that Mundell was able to collect a considerable number of cases 
which had been reported up to the end of 1915, and since then nearly 
every one responsible for the conduct of a large obstetrical service has 
been obliged to resort to laparotomy in order to prevent death from 
intra-abdominal hemorrhage following it. 

In other cases, the excessive uterine activity may so interfere with the 
placental circulation that the child succumbs to intra-uterine asphyxia. 
I have not as yet observed such an accident, but several of my friends 
have, and I regard it as so real a danger that, whenever pituitrin is 
administered to a primipara, preparations are made so that forceps 
can be applied immediately should the foetal heart sounds indicate 
danger, and in several instances I feel that the life of the child has been 
saved as the result of this precaution. 

To summarize, I consider that we have in pituitrin a potent drug, 
which, while useful in properly selected cases, may lead to disaster if 
injudiciously used. Furthermore, I believe that in its employment the 
history of ergot will be repeated, and that, instead of being used indis¬ 
criminately as at present, its employment will be eventually restricted 
to several sharply defined indications; first, in conjunction with ergot, to 
stimulate prompt contraction of the freshly delivered uterus before the 
more slowly acting ergot can exert its effect; second, to replace low for¬ 
ceps in certain multiparous women, in whom merely a slight increase in 
the vis a tergo is required; and, possibly third, to act as an adjuvant to 
castor oil and quinine in the induction of labor by Watson’s method. 
Indeed, for my part, I would willingly dispense with it altogether, except 
for the first indication, where it serves a useful, and at times an indis¬ 
pensable, purpose. 

Precipitate Labor.—In certain multiparous women, and very rarely 
in primiparae, precipitate labor may result from an abnormally slight 
degree of resistance offered by the soft parts, or from abnormally strong 
uterine and abdominal contractions, or very occasionally from the 
absence of painful sensations during laboi. 

Generally speaking, precipitate labor is not attended by serious con¬ 
sequences, although the child is sometimes extruded so rapidly that the 









762 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES 


patient is unable to secure proper attention. In such circumstances deep 
tears of the perineum are common. It sometimes happens that the 
woman is suddenly overtaken by intense labor pains and gives birth 
to the child before she can reach her bed. In such cases, the child may 
fall to the ground and sustain severe or even fatal injuries. Occasionally 
the cord is torn through and it is generally believed that the child may 
bleed to death before aid is obtainable. This, however, is unlikely, as 
experience shows that the jagged and irregular tear, which must result 
in such circumstances, would probably lead to coagulation of the blood 
and cessation of hemorrhage before a fatal issue ensued. 

If tempestuous pains come on while the patient is under the observa¬ 
tion of a physician, they should be controlled by the administration of 
chloroform, in order that the head may be held back and prevented from 
being born too brusquely. The effects of precipitate labor have been 
studied particularly by Winckel. 

Tetanic Contraction of the Uterus.—Occasionally in the first, and 
more frequently in the second stage of labor, the uterus may cease to 
relax at regular intervals, and pass into a condition of continued or 
tetanic contraction. This condition is usually encountered in prolonged 
labors, in which a mechanical obstacle is opposed to the passage of the 
child. In such cases the danger of rupture of the uterus becomes im¬ 
minent, although now and again this accident may occur when every¬ 
thing seems to be going on normally. 

So long as the tetanic condition persists, the extrusion of the contents 
of the uterus is out of the question; while at the same time the patient 
suffers intense pain, and the child is exposed to considerable danger, 
owing to interference with the placental circulation. If the condition 
is not due to an obstruction, it can be temporarily controlled by the 
administration of sedatives or an anesthetic, after which delivery should 
be effected as soon as practicable. 

Contraction of Bandl’s Ring.—Closely related to this form of dys¬ 
tocia is that which is sometimes attributed to a stricture resulting from 
tonic contraction of Bandl’s ring. Considerable attention has been di¬ 
rected to this complication within the last few years, and numerous 
cases have been described by Budin, Demelin, Cheron, Rossa, Dickinson, 
and others. The French observers believe that, while the portions of 
the uterus above and below it remain flaccid, BandFs ring can undergo 
isolated contraction, and thereby so strongly compress the neck or some 
other portion of the child as to interfere seriously with its delivery. 
Cheron has reported instances of transverse presentation in which this 
kind of stricture developed and confined the child to the upper portion 
of the uterus, at the same time offering an almost insuperable obstacle 
to the introduction of the hand for the performance of version. 

Formerly I agreed with Yeit who doubted the correctness of such 
observations, and held that in the cases described one had to deal 
\\ ith tetanic contraction of the entire active portion of the uterus. In 
this event, the lower uterine segment would be flabby, while the rest of 
the organ would be tightly contracted, there by losing its ability to expel 
its contents, and at the same time making' difficult the introduction 




CONTRACTION OF BANDL’S RING 


763 


of the hand or instruments into the uterus. Since 1919 , however, I 
have met with several cases, which have convinced me that I was in 
error and that contraction of BandFs ring may give rise to serious 
dystocia. 

My first experience was with an elderly primipara, whose labor had 
proceeded normally until the head had reached the pelvic floor. As no 
further advance occurred, 1 applied forceps to the sides of the head 
anticipating an easy extraction, but was surprised to find that strong 
traction resulted in no advance. Upon removing the blades, I found 
that difficulty was due to the fact that the neck was encircled by a 
rigid muscular ring, which held back the shoulders and opposed con¬ 
siderable resistance to the passage of a single finger past it. Under 
deep anesthesia I finally overcame the resistance manually, turned, and 
eventually extracted a living child. Within two weeks I encountered a 
similar condition, and have since met with it in several other patients. 
In one of them, cesarean section was done and the body of the uterus 
amputated, as I was unable to dilate the ring manually and the child 
was in good condition. Strange to say, all trace of the obstruction dis¬ 
appeared as soon as the organ was incised, and no further difficulty was 
experienced in extracting the child. Furthermore, careful examination 
of the extirpated organ failed to afford any explanation for the pro¬ 
duction of the clinical phenomenon. 

Clifford White in 1913 reported three personal cases in detail before 
the obstetrical section of the Royal Society of Medicine. From one 
patient he removed the unopened uterus, which on section showed the 
presence of a thick ring at the junction of its middle and lower third, 
which thus afforded indisputable evidence of the nature of the obstruc¬ 
tion. In addition he was able to collect from the literature 13 cases in 
which cesarean section had been employed to cope with a similar com¬ 
plication; while Gammeltoft in 1919 studied the question exhaustively 
upon the basis of 23 cases observed in the Copenhagen clinic. 

Greenhill in 1922 reported a remarkable case in which the condition 
developed during the birth of the child. In this instance the head was 
born spontaneously and no difficulty was experienced until strong trac¬ 
tion was required to effect delivery of the body. After birth the child 
was found to be normal, except for a deep circular constriction at the 
junction of the upper and middle thirds of the right thigh. Above it 
the dimensions were normal, while below it the leg was swollen to 
twice the size of its fellow. The swelling disappeared within a couple 
of days, and the writer held that the condition could be explained 
only by assuming the development of an isolated constricting band, 
which he located at the upper part of the cervical canal or at BandFs 

ring. 

Hour-glass Contraction.— As the result of the misuse of ergot, or of 
extensive adherence of the placenta, the uterus sometimes undergoes 
such an extreme degree of retraction during the third stage that the 
latter becomes imprisoned in its cavity. In such cases the greater pait 
of the upper segment of the uterus is tightly contracted over the re¬ 
tained placenta, while its lower portion is felt by the examining finger as 




764 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCE! 


a tightly contracted ring below the placenta. The lower uterine seg 
ment and the cervix, not having recovered from the distention to whicl 
they have been subjected, are ltabby in character, and widen from above 
downward to the vaginal insertion. From the shape thus imparted tc 
the uterus the condition is generally designated as an “ hour-glass con¬ 
traction.’' Its occurrence usually necessitates the manual removal oi 
the placenta, which can sometimes be accomplished only under anes¬ 
thesia. 

Missed Labor.—In very exceptional instances uterine contractions 
come on at or near term, and, after continuing for a variable time, 
disappear without leading to the birth of the child. The latter then 
dies, and may be retained in utero for months, undergoing mummifica¬ 
tion or putrefaction, according as the membranes have ruptured or not. 
This is known as missed labor. The term should not be applied to 
those cases in which a living child is born, as they are probably only 
examples of prolonged gestation. 

In the cases described bv Menzies and Hennig the child had been 
retained for two hundred and eighty and two hundred and ten days 
respectively after full term. In the former instance it was removed at 
autopsy, and in the latter after incision through the cervix. Krevet has 
recorded a typical case, in which the foetus, which had been retained 
for sixty-two days, was expelled spontaneously in a partially mummified 
condition, while the placenta looked as if it had been preserved in a 
hardening fluid. 

Nothing is known as to the etiology of the condition, though in the 
cases reported by Labhardt it was associated with carcinoma of the 
cervix and myoma of the uterus respectively. Cuilla is inclined to asso¬ 
ciate the phenomena with excessive fatty degeneration of the uterine 
musculature. It may readily be confounded with the retention of the 
child after the false labor following full-term tubal gestation, or with 
pregnancy in a rudimentary horn of the uterus, though a careful exami¬ 
nation should preclude the possibility of such a mistake. 

Labor should be induced as soon as the diagnosis is made, and in 
one of my patients was readily accomplished by the introduction of a 
bougie two months after the death of the foetus. 


LITERATURE 

Basset. Ueber die Bedeutung des friihzeitigen Blasensprunges fiir Geburt und 
Wochenbett. Zeitschr. f. Geb. u. Gyn., 1913, lxxiii, 566-581. 

Budin. De la dystocie causee par Uanneau de Bandl. L ’obstetrique, 1898, iii, 
289-310. 

Cheron. Des difficultes de la version causees par la retraction de Uanneau de 
Bandl. These de Paris, 1899. 

Cuilla. Ueber die fettige Degeneration der Gebarmutter in der Schwangerschaft. 
Zentralbl. f. Gyn., 1907, 1109-1117. 

Demelin. De la retraction uterine avant la rupture des membranes. L’obstet- 
rique, 1898, iii, 49-59. 

Dickinson. Caesarean Section for Impassable Contraction Ring. Surg. Gyn. and 
Obst., 1910, x, 377-391. 
















LITERATURE 


765 


Gammeltoft. Zu der durch den Bandl’schen Ring verursachten Dystokic. Archiv 
f. Gyn., 1919, cxi, 29-104. 

Greenhill. JDystocia Due to Constriction of One Thigh by the Cervix in a 
Cephalic Presentation. J. Ain. Med. Assoc., 1922, lxxviii, 98-100. 
Rellendahl. Ueber die Bedeutung des intizierten Fruchtwassers fur Mutter u. 

Kind. Beitrage zur Geb. u. Gyn., 1906, x, 320-374. 

Hennig. Ueber Lithopsedia intrauterina. Archiv f. Gyn., 1878, xiii, 292-299. 
Hofbauer. Hypophysenextract als Wehenniittel. Zentralbl. f. Gyn., 1911, 137- 
141. 

Krevet. Retention einer in der normalen Gebarmutter am richtigen Ende der 
Schwangerschaft abgestorbenen Frucht bis zum 344 Tage. Archiv f. Gyn., 
1900, lxi, 435-444. 

Labhardt. Ein Fall von “Missed Labour’ ’ bei Carcinoma uteri. Beitrage zur 
Geb. u. Gyn., 1902, vi, 437-448. 

Muller. Klinische Beobachtungen iiber Traubenzucker als wehenfordendes Mittel. 
Zentralbl. f. Gyn., 1922, 140-145. 

Mundell. Pituitrin in Labor. Am. Jour. Obst., 1916, lxxiii, 306-314. 

Parisot et Spire. La medication hypophysaire en obstetrique. Annales de Gyn. 
et d’Obst., 1911, viii, 689-706. 

Rossa. Der Contractionsring in seinem Beziehungen zur Mechanik der Geburt. 

Monatsschr. f. .Geb. u. Gyn., 1900, xii, 457-480. 

Seitz. Ueber Weichtheilschwierigkeiten, etc. Archiv f. Gyn., 1910, xc, 1-120. 
Slemons. Placental Bacteremia. J. Am. Med. Assn., 1915, lxv, 1265-1268. 

The Significance of Fever at the Time of Labor. Am. Jour. Obst., 1918, lxxviii, 
321-328. 

Veit. Ueber die Dystocie durch den Contractionsring. Monatsschr. f. Geb. u. 
Gyn., 1900, xi, 493-501. 

Warnekros. Plazentare Bakteramie. Archiv. f. Gyn., 1913, c, 173-195. 

White. The Contraction Ring as a Cause of Dystocia. Lancet, 1913, i, 604-607. 
Winckel. Ueber die Bedeutung pracipitirtcr Geburten fur die Aetiologie des 
Puerperalfiebers. Miinchen, 1884. 




CHAPTER XXXII 


DYSTOCIA DUE TO ABNORMALITIES OE THE GENERATIVE TRACT 

Vulva.—Complete atresia of the vulva or the lower portion of the 
vagina is usually congenital, and unless corrected by operative measures 
would oppose an insuperable obstacle to conception. Von Meer has 
reported an exceptional case in which the lower two-thirds of the vagina 
were lacking, while the upper third communicated with the bladder. 
Coitus was accomplished per urethram, through which a three months’ 
foetus was subsequently expelled. 

More frequently vulval atresia is incomplete, and is due to adhesions 
and cicatricial changes resulting from injury or inflammatory processes. 
The defect may offer a considerable obstacle to labor, but the resistance 
is usually overcome by the continued pressure exerted by the head, 
though frequently only at the expense of deep perineal tears. 

I have seen cases in which an almost imperforate hymen had re¬ 
mained intact until the time of labor, and only ruptured when distended 
by the child’s head. In rare instances, as was pointed out by Coester, a 
thick septate hymen may form a bridge of tissue opposing the advance 
of the presenting part, and may require to be cut through before delivery 
can be completed. 

Especially in elderly primiparae, the vulval outlet may be very small, 
rigid, and altogether lacking in elasticity, and causes dystocia and pre¬ 
disposes to extensive laceration. Again, as the result of pressure or 
renal lesions, the vulva may become so edematous that its orifice is 
almost occluded. In these circumstances the soft parts may be so brittle 
that they are peculiarly liable to laceration. Moreover, when excessive 
edema has persisted for some time, the tone of the tissues may be so 
lowered that they even become gangrenous as a result of the traumatism 
incident to labor. 

r J he formation of thrombi or hematomata about the vulva, although 
more common during the puerperium, occasionally occurs during the 
latter part of pregnancy or at the time of labor, and may give rise to 
slight dystocia. Inflammatory lesions about the vulva, as well as 
malignant new growths, may have a similar effect. 

Vagina. Complete vaginal atresia is nearly always congenital in 
origin, and is an effectual bar to pregnancy. Incomplete forms, on the 
other hand, are sometimes manifestations of faulty development, but 
more frequently result from accidental complications. 

A ery occasionally the vagina is divided into tjvo halves by a longi¬ 
tudinal septum extending from the vulva to the cervix; more often the 
structure is incomplete, being limited to either the upper or lower por- 

766 


VAGINA 


767 


tion of the canal. Such conditions are frequently associated with abnor¬ 
malities in the development of the generative tract, and their detection 
should always lead to further careful examination, with a view to deter¬ 
mining whether partial or complete duplicity of the uterus exists. 

A complete longitudinal septum rarely gives rise to dystocia, as the 
half of the vagina through which the child descends gradually undergoes 
satisfactory dilatation. On the other hand, an incomplete septum occa¬ 
sionally interferes with the descent of the head, becoming stretched over 
it as a fleshy band of varying thickness. Such structures are usually 
torn through spontaneously, but occasionally are so resistant that they 
must be ligated and severed by the obstetrician. 

Occasionally the vagina may be obstructed by ringlike strictures or 
bands of congenital origin. These, however, rarelv offer a serious ob- 
stacle to labor, as they usually yield before the oncoming head, though 
in extreme cases incision may be necessary. 

Sometimes the upper portion of the vagina is separated from the re¬ 
mainder of the canal by a diaphragmlike structure with a small central 
opening. Such a condition is occasionally mistaken by inexperienced 
observers for the vaginal fornix, and at the time of labor for the undi¬ 
lated external os. A careful examination, however, should reveal the 
presence of the opening, through which a finger can be passed, the cervix 
then being distinguished above it. After the external os is completely 
dilated, the head impinges upon the abnormal structure and causes it to 
bulge downward. If it does not yield, slight pressure upon its opening 
will usually lead to further dilatation; but if this is not effectual crucial 
incisions may be necessary in order to allow of delivery. 

Accidental atresia is always secondary in origin, and results from 
the formation of adhesions following injuries or inflammatory processes. 
It sometimes follows severe puerperal infections, during the course of 
which the entire lining of the vagina may have sloughed off, so that as 
healing occurs its lumen has become almost entirely obliterated. A 
similar result is sometimes noted after diphtheria, smallpox, cholera, 
and syphilis; while in rare instances, as in a case reported by Schenk, 
it may be due to the action of corrosive fluids injected into the vagina 
in the hope of inducing abortion. That the most frequent cause of 
atresia is injury or inflammatory conditions following labor is shown by 
the fact that 209 of the 1,000 cases collected by Neugebauer presented 
such a history. 

The effects of such conditions vary greatly. In the majority of cases, 
owing to the softening of the tissues incident to pregnancy, the obstruc¬ 
tion is gradually overcome by the pressure exerted by the presenting 
part; less often manual or hydrostatic dilatation or incisions may become 
necessary. If, however, the structure is so resistant that spontaneous 
dilatation appears improbable, cesarean section should be performed at 
the onset of labor. Full literature concerning this complication is to be 
found in the articles of Ward and Brindeau. 

Among the rare causes of serious dystocia, vaginal neoplasms are 
worthy of mention. Gilder, in 1893, having collected 60 cases from the 
literature. The obstruction was due to the presence of cystic structures, 




768 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRAC' 

fibromata, carcinomata, sarcomata, or hematomata, arising from th 
vaginal walls or the surrounding tissues. When the tumor is accessibl 
it is best treated by excision, no matter what its origin. If this is no 
practicable, and the growth is cystic, tapping becomes the operation o 
choice. The presence of a solid tumor may occasionally afford an indi 
cation for cesarean section. Sasonoff observed a case in which a vagina 
hematoma developed so rapidly after the birth of one twin as to inter 
fere seriously with the delivery of the second child. 

Exceptional^ tetanic contraction of the levator ani muscle may seri 
ously interfere with the descent of the head. In this condition, whicl 
is analogous to the vaginismus of non-pregnant women, a thick, ring 
like structure completely encircles and markedly constricts the vagim 
several centimeters above the vulva. Hue, in 1906, collected a number 01 i 
such cases. 

Ordinarily the condition yields under the influence of anesthesia, 
though in one of my patients the obstruction persisted in spite of pro¬ 
found anesthesia, and it was only after steady pressure had been exerted 
upon it for some minutes that it relaxed sufficiently to permit the passage I 
of the hand folded in the shape of a cone. 

Cervix.—Inasmuch as complete atresia of the cervix is incompatible 
with conception, it must be assumed, whenever such a condition is met 
with in a pregnant woman, that conception had occurred before its 
formation, or that the atresia was only relative. 

A good illustration is afforded by the so-called conglutinatio orificii 
externi. In this condition the cervical canal undergoes complete ob¬ 
literation at the time of labor, while the os remains extremely small with 
very thin margins, the presenting part being separated from the vagina 
only by a thin layer of cervical tissue. Formerly, this appearance was 
attributed to the existence of adhesions between the lips of the external 
os, but Schroeder was probably right in stating that it is simply due to a 
very small and resistant opening. Ordinarily, complete dilatation 
promptly follows from pressure with a finger tip, although in rare 
instances manual dilatation or crucial incisions may become necessary. 

Cicatricial stenosis of the cervix frequently follows difficult labor 
associated with infection and considerable destruction of tissue. Less 
frequently it is due to syphilitic ulceration and induration, several in¬ 
stances of which have been reported by Le Bigot. Now and again it 
results from the employment of corrosive substances for the purpose of 
producing abortion; while occasionally it is a sequel to gynecological 
operations. 

Ordinarily, owing to the softening and succulence of the tissues inci¬ 
dent to pregnancy, the stenosis, whatever its cause, gradually yields to 
the natural forces; but in other cases dilatation has to be accomplished 
by manual methods or by the employment of rubber bags. In rare 
instances, however, the resistance may be too great to be so overcome, 
and in such cases cesarean section should be performed early in labor. 

In a number of my patients cesarean section was necessary on account 
of complete atresia of the external os. As several of them had previous 
spontaneous labors, and as no history of inflammatory trouble or of 










UTERINE DISPLACEMENTS 


769 


K" 


ittempts at abortion could l)e elicited, the cause of the condition re¬ 
named doubtful. In other cases, the atresia had followed high amputa- 
ion of the cervix, and in one of them no trace of an opening could be 
bund in the organ removed after cesarean section, although it must 
lave existed at the time of conception. Ahlstrbm, in 1904, thoroughly 
’eviewed the literature. 

Rigidity of Cervix. —Reference has already been made to the unyield¬ 
ing cervix of elderly primiparae. Occasionally still greater rigidity is 
Bncountered in patients who have suffered from inflammatory lesions, 
though such conditions rarely give rise to serious dystocia. On the 
other hand, in certain cases of hypertrophic elongation of the cervix, 
spontaneous dilatation does not occur, although, as a rule, one is sur¬ 
prised to see how completely the abnormality may be effaced during the 
course of pregnancy. 

Uterine Displacements.— Anteflexion. —Marked anteflexion of the 
uterus is usually associated with a pendulous abdomen. In primiparae 
the condition is usually indicative of disproportion between the size of 
the head and the pelvis; whereas in multiparae it is more often an 
accompaniment of the flaccidity of the abdominal walls incident to re¬ 
peated childbearing. In the latter class of cases the abnormal position 
of the uterus prevents the force of its contractions from being properly 
transmitted to the cervix, hence the dilatation of the latter is inter¬ 
fered with. Marked improvement in this respect usually follows the 
maintenance of the uterus in an approximately normal position by means 
of a properly fitting abdominal bandage. 

Retroflexion. —As was said in Chapter XXVII, retroflexion of the 
pregnant uterus is usually incompatible with advanced pregnancy, since, 
if spontaneous or artificial reposition does not occur, the patient either 
aborts or presents symptoms of incarceration before the end of the fourth 
month. In very exceptional instances, however, pregnancy may go on 
to term, in which event the fundus remains attached to the floor of the 
pelvis, while the anterior wall hypertrophies to such an extent as to 
afford room for the product of conception. In this condition, which is 
known as sacculation, the head of the child occupies the fundus, while 
the cervix is sharply bent and so drawn up that the external os lies above 
the upper margin of the symphysis pubis. At the time of labor the 
contractions tend to force the child through the most dependent portion 
of the uterus, while the cervix dilates only partially, so that spontaneous 
labor is out of the question, and rupture of the uterus may occur, as 
in a case reported by Campbell. For these reasons cesarean section will 
afford the most conservative method of delivery, and at the same time 
make possible the reposition of the organ. 

Dystocia Due to Operations for the Relief of Retroflexion of the 
Uterus. —Unfortunately, several of the operations which have been sug¬ 
gested for the relief of retroflexion of the non-pregnant uterus, while 
rectifying the condition, occasionally give rise to serious dystocia. Until 
recentlv it was generally believed that this could only follow ventro- 
or vaginal fixation of the uterus, hut as the result of my own experience 
T have been reluctantly forced to admit that it may also exceptionally 








770 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT 


occur after suspension, even when performed by competent operators 
with the most approved technic. Thus, it may occasionally happen, 
as the result of infection or some other unknown condition, that the 
proposed suspension becomes converted into a fixation, and as a conse¬ 
quence the uterus becomes firmly attached to the anterior abdominal 
wall by a thick adhesion, which will neither break nor stretch during 
pregnancy. 

In this event, serious difficulty may arise at the time of labor in one 
of three ways: Most frequently, the adherent anterior wall of the uterus 
is unable to expand, so that the enlargement of the organ is effected 
solely at the expense of its posterior wall, while the hypertrophied an¬ 
terior wall is represented by a thick mass of muscle extending from the 
point of fixation to the cervix, and obstructing the superior strait. As 
the uterus expands, traction is made upon the cervix, which is gradually 
drawn upward from its normal position, until the external os is on a 
level with, or considerably above, the promontory of the sacrum, so that 
in extreme cases its posterior lip may be opposite the second or third 
lumbar vertebra. When labor sets in, dilatation of the cervix is effected 
very imperfectly, since the bag of waters and the presenting part, instead 
of impinging upon it, are forced down upon the thickened anterior 
uterine wall. Accordingly, the uterine contractions, no matter how 
strong they may be, are unable to effect the completion of labor, and, 
unless suitable operative aid is forthcoming, rupture of the uterus will 
occur, as in the cases reported by Dickinson and others. 

Less frequently, as in the case reported by Lynch, the anterior wall 
of the uterus does not hypertrophy, and in such cases the dystocia will 
be due entirely to the upward dislocation of the cervix. 

In other instances, as in the case which I reported in 1906, both 
walls hypertrophy, and, because of the limited space available between 
the area of fixation and the cervix, the anterior wall buckles and becomes 
folded upon itself, instead of forming a thick muscular pad in front of 
the cervix. In such circumstances, the lower part of the uterine cavity 
is divided by a crescentic fold, with a sacculation in front of it, in which 
portions of the foetus may lie, and thus be inaccessible to the operating 
hand. Moreover, the dystocia is exaggerated by the upward displace¬ 
ment of the cervix, as well as by the fold itself interfering with the 
engagement of the presenting part, as is indicated in the illustration 
(Fig. 528). 

Andrews, in 1905, collected the histories of 395 cases of pregnancy 
occurring in women who had been subjected to ventral fixation or suspen¬ 
sion. In the 359 patients who went to full term, delivery was effected by 
cesarean section in 20, by forceps in 21 instances, and once by crani¬ 
otomy. This, however, does not exhaust the untoward effects of the 
operation, as the uterus ruptured in 3 other cases, and transverse pres¬ 
entations were noted in 10 instances. In 1906, I was able to increase 
still further the list of complications, and collected from the literature 
36 cases of cesarean section, as well as 2 additional cases of craniotomy. 
Since that time many more cases have been reported, and the condition 
is now recognized as a definite factor in the production of dystocia. 




UTERINE DISPLACEMENTS 


771 


In view of such experiences, the question arises whether the perform¬ 
ance of suspensory operations of any kind is justifiable in women during 
■ the childbearing period. Formerly I held that, while ventrofixation was 
contra-indicated, suspension was practically devoid of danger; but, in 
view of what we now know, it must be admitted that the latter operation 



Fig. 528.—Dystocia Following Ventrosuspension. Sacculation of Anterior 


Uterine Wall. X l / z . 

Ad., adhesion between uterus and anterior abdominal wall; A.W., abdominal wall; U.W., 
uterine wall; B., bladder; F, folded anterior uterine wall; P., placenta. 

may also give rise to serious dystocia. Accordingly, I feel that during 
the childbearing period fixation should not be done except when the 
tubes or ovaries are likewise removed, and that suspension should be 
practiced only when urgently indicated. For a time it was felt that 
Gilliam’s operation would not be followed by dystocia, but after my 
friend Dr. F. S. Newell, of Boston, had been obliged to resort to 
cesarean section after that operation, it is apparent that even it is not 
innocuous from an obstetrical point of view. 

The vaginofixation , suggested by Diihrssen and Mackenrodt, in which 
















772 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACI 


the fundus was firmly stitched to the anterior vaginal wall, has beei 
followed by such serious dystocia that it has been practically abandonee 
during the childbearing period. Riihl has collected 9 cases of cesareai 
section following this operation. After Esch had reported that simila 
complications might follow the Schauta-Wertheim interposition opera 
tion for the cure of prolapse of the uterus, the operation was restrictee j 
to patients who had passed the menopause, or who had been sterilize( 
by removal of the ovaries or excision of the tubes. Nevertheless, Weibe 
in 1916 reported that he had been obliged to perform cesarean sectioi 
upon two patients in whom the latter precaution had been omitted. 

Prolapse .—Pregnancy cannot go on to full term when the uterus i 
completely prolapsed, but it may do so in the incomplete variety. L | 
such cases the fundus occupies its usual level, while the protrusioi 
from the vulva is made possible by elongation of the hypertrophiec 
cervix. As a rule, the latter becomes retracted as pregnancy advances 
though in rare cases it may continue to protrude from the vulva an< 
become so edematous and swollen as to give rise to serious dystocia 
Under such circumstances multiple incisions may be necessary in orde 
to effect delivery. Even though dystocia may not result, the conditioi 
greatly increases the danger of labor. One of my patients, who wa; 
delivered spontaneously at term, was suffering from intrapartum infec 
tion when admitted to the service and died a’few days later from strepto 
coccus infection. Although she had not been examined vaginally, th< 
fact that the external os protruded from the vulva afforded a rationa 
explanation for the occurrence of infection. 

Dystocia Due to Tumors of the Generative Tract and Pelvis.— Car 
cinoma of the Cervix .—The effect of this condition upon pregnancy an< 
labor and its appropriate treatment has been considered in Chapte 
XXVII. 

Fibromyomata of the Uterus .—Myomata were observed by Schaut? 
and Pinard in 54 and 84 out of 55,311 and 13,915 consecutive cases ol 
labor respectively—0.1 and 0.6 per cent. It is a matter of genera 
observation that women suffering from this disease are relatively sterile 
Thus, 75 per cent, of Schauta’s patients were over thirty years of ag( 
when the first pregnancy occurred. 

The obstacle to conception is most marked when the tumor is o 
the submucous or interstitial variety. Moreover, when pregnancy oc 
curs, owing to the hemorrhagic changes in the endometrium, which are 
frequently associated with the presence of submucous myomata, there is 
an increased tendency toward premature expulsion of the ovum. Or 
the other hand, pregnancy is not without influence upon the tumors 
themselves, which frequently increase rapidly in size, more as a result 
of edema than of actual hypertrophy. Furthermore, owing to the pres¬ 
sure to which they are subjected by the growing ovum, the softened 
tumors may undergo considerable changes in shape. Occasionally the 
pedicle of a subserous myoma may become twisted and gangrene and 
peritonitis may ensue. 

The diagnosis of the association of pregnancy and myomata is not 
always easy. Hemorrhage may occur at intervals as the result of 




: 















TUMORS OF THE GENERATIVE TRACT AND PELVIS 773 


changes in the endometrium, and be mistaken by the patient herself 
for the menstrual flow, so that the idea of pregnancy may not suggest 
itself for months or until on abortion occurs. On the other hand, a 
sudden increase in the rapidity of the growth of the uterine tumor 
should direct attention to the possibility of pregnancy, and the diagnosis 
becomes assured when careful palpation shows the presence of soft areas 
interspersed between the firmer myomatous nodules. Subperitoneal 
myomata occasionally escape observation, being mistaken for the small 
parts, or sometimes for the head of the foetus, so that a diagnosis of 
multiple pregnancy may be made. 

At the time of labor the effect exerted by the myomata depends en¬ 
tirely upon their size and situation. Generally speaking, subserous 
tumors are without great significance, except when their large size leads 
to pressure symptoms, or when a pedunculated tumor prolapses into the 
pelvic cavity. On the other hand, interstitial myomata, developed in 
the cervix or lower uterine segment, may so obstruct the pelvic cavity 
that normal delivery will be impossible. As a result of the uterine con¬ 
tractions, a submucous myoma may become partially separated from 
its bed and protrude from the cervix as a polypoid mass. In such cir¬ 
cumstances, since it effectively prevents the descent of the head, it must 
be removed by cutting through the pedicle. 

Even when the tumor does not interfere with the course of labor 
by its size and situation, it predisposes to the occurrence of abnormal 
i presentations. Thus Olshausen, in tabulating the cases reported in the 
literature, found only 53 per cent, of vertex presentations, as compared 
with 24 and 19 per cent, of breech and transverse presentations, respec¬ 
tively. Schauta, however, noted abnormal presentations in only 8 per 
cent, of his personal cases. Moreover, the mere presence of the tumor 
i may so interfere with the character of the uterine contractions as to 
i cause dystocia, as well as to favor the occurrence of postpartum hemor¬ 
rhage. The latter is due partly to the fact that the myomatous nodules 
interfere with the normal contraction and retraction of the uterus, and 
partly because they may offer a mechanical obstacle to the separation 
and expulsion of the placenta. 

In the puerperium, myomata frequently undergo degenerative 
changes, and if they have been subjected to prolonged pressure may 
become gangrenous. On the other hand, in certain cases the effect of 
pregnancy is beneficent, as the tumors may undergo puerperal involu¬ 
tion, and thus become smaller or occasionally disappear entirely. 

In preantiseptic times the outlook in the case of labors complicated 
by the presence of myomatous tumors was most serious. Thus, the 
maternal and foetal mortality were respectively 25 and 79 per cent, in 
‘307 cases collected from the literature by Lefour in 1880. At present, 
thanks to early diagnosis and prompt recourse to operative procedures 
n suitable cases, the prognosis is much more favorable. Pinard reported 
that labor was spontaneous in 54, and required operative aid in 30 of 
iis cases, with the maternal mortality of only 3.6 per cent.; while 
Schauta stated that in only 4 per cent, of his cases was radical operative 
nterference necessary. 




774 DYSTOCIA DUE TO ABNORMLAITIES OF GENERATIVE TRACT 


In case of extreme distention, serious hemorrhage, or symptoms of 
impaction occurring before the child has attained the period of viability, 
laparotomy is indicated; but whether removal of the tumor can be best 
effected by excision, enucleation, supravaginal or total hysterectomy will 
vary according to circumstances and the predilections of the individual 
operator. Generally speaking, isolated subserous myomata are best 
treated by excision, and those of the interstitial variety by enucleation; 
whereas, if numerous tumors are present, supravaginal hysterectomy is 
indicated without reference to the existence of pregnancy. 

Myomectomy and enucleation are frequently followed by abortion oi 
miscarriage, but do not necessarily destroy all chance of saving the life 


of the child. Notwithstanding this, however, my own inclination is 


toward supravaginal amputation, whenever operation is imperatively 
demanded, as being a less dangerous procedure as far as the mother is 
concerned. Landau in 21 personal operations reported a mortality of 
4.8 per cent., as compared with 10.6 per cent, in 471 operations collected 
from the literature by Carstens. 

If serious symptoms do not supervene during pregnancy, operative 
interference should be deferred until the time of labor, or shortly before 
its expected onset, since the tumor may so change its shape or position as 
to render an operation unnecessary from an obstetrical point of view 
Thus, in one of my patients, a tumor the size of a fist was found ir 
the upper part of the cervix at the fifth month, and gave every indicatior 
of offering a serious obstacle to delivery. To my surprise, however 
when she returned at the end of pregnancy for a cesarean section, th( 
tumor had risen out of the pelvis, so that operation was not thought 
necessary, and a few days later an easy spontaneous delivery occurred 

So fortunate an outcome, however, cannot always be expected, anc 
in any event the patient should be examined thoroughly, and under anes¬ 
thesia if necessary, shortly before the expected date of confinement. Ii 
the tumor is found to be firmly impacted in the pelvis, cesarean sectior 
should be performed before labor sets in, followed by supravaginal am¬ 
putation or enucleation, according to the judgment of the operator. Or 
the other hand, if there is apparently no danger of impaction, and spon¬ 
taneous delivery seems probable, the patient should be allowed to g( 
into labor spontaneously. If, however, a mistake in prognosis has beer 
made, and symptoms of obstruction occur, cesarean section should b( 
promptly performed in preference to attempts at delivery by the mort 
usual obstetrical procedures. 

It should be remembered that the completion of labor does noi 
necessarily indicate that all danger is passed, since, as has previously 
been indicated, the tumor may undergo gangrenous changes during thf 
puerperium. Consequently, the occurrence of fever and abdominal pair : 
should direct one’s attention to such a possibility and make one considei 
the advisability of laparotomy. 

Ovarian Tumors .-The presence of an ovarian tumor is one of th< 
most serious complications of pregnancy, as it markedly increases th< 
probability of abortion and frequently offers an insuperable obstacle t< 







TUMORS OF THE GENERATIVE TRACT AND PELVIS 


775 



delivery at the time of labor. Moreover, even after a spontaneous labor, 
its presence may give rise to disturbances during the puerperium. 

While any variety of ovarian tumor may complicate pregnancy and 
labor, dermoid cysts have been described comparatively frequently in 
this connection. Thus, in 107 cases collected by McKerron, in which 
the nature of the tumor was stated, there were 47 cystomata, 46 dermoid 
cysts, 9 malignant tumors, 5 fibromata, and 2 colloid cysts; while Spen¬ 
cer observed dermoid cysts in 12 of his 41 patients. Swan, in 1898, was 
able to collect 14 cases of solid ovarian tumor. 

Of the 321 pregnancies complicated by ovarian tumors which were 
collected by Iiemy, spontaneous abortion or premature labor occurred 


Fig. 529. —Dystocia Due to Ovarian Cyst (Bumm). 

in 17 per cent, of the cases. As has been indicated, tumors may also give 
rise to serious dystocia at the time of labor. Thus, McKerron, in 720 
cases collected from the literature in which pregnancy had been allowed 
to run its course without interference, noted a maternal mortality of 21 
per cent., while more than half of the children were lost. The majority 
of these cases, however, were reported prior to the general employment 
of radical surgical methods, very few laparotomies having been per¬ 
formed, and interference for the most part being limited to puncture or 
incision of cysts through the vagina. Moreover, the danger to the 
patient does not end with the birth of the child, as in not a few 
cases peritonitis follows gangrene of the tumor resulting from excessive 
pressure, while in others torsion of the pedicle may lead to a fatal ter¬ 
mination. 











776 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACI 


Again, the cyst may rupture and extrude its contents into the peri 
toneal cavity during a spontaneous labor or as the result of operativ< 
interference. This event is a matter of indifference with the ordinar 
cystomata, but in the case of a dermoid cyst is frequently followed b; 
fatal peritonitis. When the tumor occupies the pelvic cavity it ma; 
lead to rupture of the uterus, or, if that does not occur, the tumor ma; 
be forced into the vagina and occasionally even into the rectum. Whil< 
spontaneous rupture may occur, it is sometimes surprising that it is no 
more frequent. Thus, in one of my patients a unilocular cyst, whicl 
was impacted in the pelvic cavity, led to rupture of the uterus instea< 
of its own walls, although the latter did not exceed one millimeter ii 
thickness. 

Unfortunately, the presence of an ovarian tumor complicating preg 
nancy often remains entirely unsuspected, the condition having beei 
recognized in only 18 of McKerroiFs first series of cases. Nevertheless | 
careful antepartum examination of all pregnant women should certainbl 
eliminate a large proportion of these errors. Moreover, failure of th< 
presenting part to engage, when the pelvis is known to be normal, sug 
gests an obstructing mass. On the other hand, if the tumor does no I 
occupy the pelvic cavity, the diagnosis may be extremely difficult, as th< 
abdominal enlargement may be attributed to the presence of twin preg 
nancy or hydramnios, and the true condition is not recognized unti 
after labor. 

If the ovarian tumor is detected prior to the last month of preg¬ 
nancy, it should be removed immediately by laparotomy, as it is gen 
erally admitted that the operation is attended by but little danger j 
Thus, Heil, in 1904, collected from the literature 188 such operations 
with a maternal mortality of 2.1 per cent. 

It has been objected that such a procedure increases the chances oJ 
premature delivery, which occurred in 19.47 per cent, of HeiFs cases, bui 
in only half so many of Szymanowicz’s personal cases. It should, how¬ 
ever, be remembered that a similar accident may take place even if the 
patient is not interfered with, having been noted in 17 per cent, o! 
Remy’s cases. This difference is so slight that the chances for the chile 
are little, if at all, impaired by operation, while those of the mothei 
are markedly improved. 

On the other hand, when the diagnosis is not made until late ir 
pregnancy, it is usually advisable to postpone the operation until term, 
for the reason that the fresh abdominal cicatrix is not well adapted tc 
the strain of parturition. Consequently, if the tfimor is impacted in the 
pelvis, cesarean section should be done at an appointed time, and fol-1 
lowed by the removal of the tumor. If, however, it is not impacted 
some authorities prefer to allow the patient to go into spontaneous laboi 
and to remove the tumor later in the puerperium. Bland Sutton 
Spencer and others advise that the tumor alone be removed, and that 
the birth of the child be left to Nature, or at most be assisted by forceps. 
I, however, am of the opinion that the double operation is preferable, 
believing that a woman should not be subjected to the strain of laboi 
immediately following an abdominal operation. 







TUMORS OF THE GENERATIVE TRACT AND PELVIS 777 


Formerly it was advised to attempt the reposition of the mass under 
anesthesia. This practice, however, is not to be recommended, for the 
reason that the tumor is liable to give rise to trouble during the puer- 
perium. Moreover, since operative interference will be necessary sooner 
or later, it would seem far better to institute radical measures without 
delay. Puncture through the vagina, although strongly advocated at 
one time, must be considered as a dangerous and extremely reprehensible 
practice, inasmuch as we possess no means of preventing the tumor 
contents from contaminating the peritoneal cavity. Furthermore, the 
■statistics collected by Jones in 1913, indicate that the procedure is 
attended by a greater mortality than purely expectant treatment. 

If spontaneous labor has occurred, the patient should be carefully 
watched during the puerperium for the appearance of untoward symp¬ 
toms. Should they arise, prompt operation is imperatively demanded. 
In any event, a woman suffering from an ovarian tumor should not be 
discharged from treatment until the tumor has been removed, or at 
least until the importance of operative procedures has been strongly 
urged upon her. 

Tumors of Other Origin .—Labor is occasionally obstructed by tumors 
3f various origin, which encroach upon the cavity of the pelvis to such 
m extent as to render delivery difficult or even impossible. In Chapter 
XXXVIII reference will be made to dystocia due to tumors arising 
from the pelvic walls. 

In rare instances a normal sized or enlarged icidney or spleen may 
prolapse into the pelvic cavity and offer an obstacle to labor. Bland 
Sutton has added an additional case of displaced kidney complicating 
pregnancy to those collected by Cragin; and has also reported the 
removal of a prolapsed spleen in the second month of pregnancy, which 
would have given rise to serious dystocia at the time of labor had it re¬ 
mained in situ. 

Echinococcus cysts are occasionally implanted in the pelvic cavity. 
Franta, in 1902, collected 22 cases noted during pregnancy and dis¬ 
cussed their effect upon the course of labor. 

In Chapter XXX reference was made to those cases in which an old 
extra-uterine gestation sac so obstructed the pelvic canal as to interfere 
with the delivery of a subsequent intra-uterine pregnancy. 

Enterocele or hernia through *the vaginal walls occasionally gives rise 
to dystocia, though in the majority of cases the prolapsed intestine can 
be replaced and the obstacle temporarily overcome. Where this is not 
possible, cesarean section is indicated as a more conservative procedure 
than forcibly dragging the child over a large irreducible hernia. 

In occasional instances tumors of the bladder may likewise offer an 
impediment to the passage of the child, though it is rarely so serious as 
to demand operative interference. On the other hand, it has sometimes 
been necessary to remove a large calculus from the bladder before de¬ 
livery could be effected. In Neer’s case the stone was almost spherical in 
shape, and measured 2.75 inches in its greatest diameter. 

A large rectocele or cystocele , though occasionally offering slight 




778 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT 


obstacle to labor, can generally be replaced while delivery is being 
effected. 

Tumors arising from the lower part of the rectum or pelvic con¬ 
nective tissue may likewise give rise to serious dystocia; Pederson, in 
1922, having collected a series of cases in which carcinoma of the rectum 
rendered cesarean section necessary. 


LITERATURE 



Ahlstrom. Zwei Kaiserschnitte wegen narbiger Verengerung cler weichen Ge- 
burtswege. Mitth. aus d. gyn. Klinik des Prof. Engstroms, 1904, vi, 289-304, 

Andrews. The Effect of Ventral Fixation of the Uterus upon Subsequent Preg¬ 
nancy and Labour. Jour. Obst. and Gyn. Brit. Emp., 1905, viii, 97-125. 

Bland Sutton. The Surgery of Pregnancy and Labour Complicated with Tu¬ 
mours. Lancet, 1901, i, 382-386; 452-456; 529-532. 

Brindeau. De 1 ’atresie acquise du vagin au point de vue obstetricale. L ’obstet- 
rique, 1901, vi, 97-122. 

Campbell. Rupture of an Incarcerated Retroverted Gravid Uterus. Jour. Obst, 
and Gyn. Brit. Emp., 1908, xiv, 402-404. 

Carstens. Fibroid Tumor Complicating Pregnancy. Am. Jour. Obst., 1909, lix 
447-462. 




Coester. L T eber Geburtshindernisse durch hvmenale Balken, etc. D. I. Marburg 
1900. 

Cragin. Congenital Pelvic Kidney Obstructing the Parturient Canal. Amer. Jour 
Obst., 1898, xxxviii, 36-41. 

Dickinson. Pregnancy Following Ventrofixation. Amer. Jour. Obst., 1901, xliv 
34-45. 

Esch. Ueber Schwangerschaft und Geburt nach Schauta-Wertheim Prolaps-opera 
tion. Gyn. Rundschau, 1911, v, 335-338. 

Franta. Les kystes hydatiques du bassin et de 1 ’abdomen au point de vue de la 
dystocie. Annales de gyn. et d’obst., 1902, lvii, 165-197; 296-308. 

Guder. Ueber Geschwiilste der Vagina als Schwangerschafts- und Geburtskompli- 
kationen. D. I., Bern, 1889. 

Heil. Beitrag zur Ovariotomie in der Schwangerschaft. Miinchener med 
Wochenschr., 1904, li, Nr. 3. 

Hu£). Quelques recherches sur 1 ’ampliation du diaphragme pelvien, etc. Paris, 
1906. 

Jones. Ovarian Cysts in Relation to Childbearing. Surg. Gyn. and Obst., 1913 
xvi, 63-73. 

Landau. Myom bei Schwangerschaft, Geburt und Wochenbett. Berlin u. Wien 
1910. 

Le Bigot. De 1 ’influence du chancre syphilitique du col de 1 ’uterus sur l’ac 
couchement. These de Paris, 1899. 

Lefour. Quoted by Olshausen. 

Lynch. Kaiserschnitt und schwere Geburtsstorung infolge Ventro-fixation unc 
Suspension. Monatsschr. f. Geb. u. Gyn., 1904, xix, 521-538. 

McKerron. Pregnancy with Ovarian Tumour. London, 1906. 

VON Meer. Conception und Abort durch den Ausfiihrungsgang der Blase be 
angeborener Defect der Vagina. Beitrage zur Geb. u. Gyn., 1900, iii, 409-424 

Neer. Dystocia from Large Bladder Stone Impacted in the Pelvis. Jour. Am 
Med. Assoc., 1919, lxxvii, 479-480. 













LITERATURE 


779 


Neugebauer. Zur Lehre von dem angeborenen und orworbenen Verwaehsimgcn 
und Verengerungen der Scheide. Berlin, 1895. 

Oldham. Sacculation of the Uterus. A Case of Retroflexion of the Gravid Uterus. 
Trans. Lond. Obst. Soc., 1860, i, 317-322. 

Olshausen. Myom und Schwangerschaft. Veit’s Handbuch der Gyn., 1897, ii, 
765-814. 

Pederson. Dystocia Caused by Diseases of the Rectum. Acta Gyn. Scandinavica, 
1922, i, 445-458. 

Pinard. Fibromes et grossesse. Annales de gyn. et d’obst., 1901, lv, 165-167. 

Remy. De la grossesse compliquee de kyste ovarique. Paris, 1886. 

Ruhl. Kritisehe Bemerkungen iiber Geburtsstorungen nach Vaginalfixatio-uteri. 
Monatsschr. f. Geb. u. Gyn., 1901, xiv, 477-490. 

Sasonoff. Etude du thrombus de la vulve et du vagin. Annales de gyn. et 
d’obst., 1884, xxii, 447-467. 

Schauta. Myom und Geburt. Compte-rendu XVI e Congres internat. de medecine, 
vii, 8-32. Budapest, 1910. 

Schenk. Hochgradige frische Aetzstenose der Cervix und des Fornix in der 
Schwangerschaft. Zentralbl. f. Gyn., 1900, xxiv, 161-170. 

Schroeder. Conglutinatio orificii externi. Lehrbuch der Geburtsh., XIII, Aufl., 
1899, 590-592. 

Spencer. Ovarian Tumors Complicating Pregnancy, Labor and the Puerperium. 
Surg. Gyn. and Obst., 1909, viii, 461-466. 

Swan. The Management of Solid Tumours of the Ovaries Complicating Preg¬ 
nancy, with Report of a Successful Case. Bull. Johns Hopkins Hosp., 1898, 
ix, 56-61. 

Szymanowicz. Kvstes de l’ovaire et gestation. Gyn. et Obst., 1922, vi, 405-419. 

Ward. Atresia Vaginae Complicating Labour. Obstetrics, 1899, i, 623-625. 

Weibel. Ueber Schwangerschaft und Geburt nach Interpositio uteri vesico- 
vaginalis. Archiv f. Gvn., 1916, cv, 65-73. 

Williams. Dystocia Following Ventral Suspension and Fixation of the Uterus. 
Trans. Southern Surgical and Gyn. Association, 1906, xix. 










CHAPTER XXXIII 
CONTRACTED PELVIS 

We designate a pelvis as contracted when it is so shortened in one or 
more of its diameters as to affect materially the mechanism of labor, 
but without necessarily retarding the birth of the child. According 
to Litzmann, this is the case when the conjugata vera measures 9.5 centi¬ 
meters or less in flat, and 10 centimeters or less in generally contracted 
pelves. 

History.—Inasmuch as Vesalius was the first to describe the normal 
pelvis correctly, it is clear that the conception of abnormal forms could 
not have existed before his time. His pupil, J. C. Arantius (1530- 
1589), gave the first anatomical description of such a pelvis, but his 
discovery exerted no appreciable effect upon the obstetrical art of the 
period, for the reason that Ambroise Pare still held to the old view 
of the separation of the pubic bones during labor, and promulgated it in 
his writings. 

During the next century knowledge of the subject advanced but 
slowly, and we find Mauriceau (1637-1709) stating that in his very 
large experience he had observed only two instances of contracted pelvis. 
In one of these Chamberlen was permitted to apply the forceps invented 
by his uncle, but failed to effect a delivery. 

We are indebted to Heinrich van Deventer for our first knowledge 
of contracted pelves from an obstetrical standpoint. In his “New Light 
for Midwives,” which appeared in 1701, he described the generally con¬ 
tracted and the flat varieties, and discussed the influence which they 
exert upon labor. From that time on mention of the subject is to be 
found in all the text-books, De la Motte, Puzos, and Dionis being the 
obstetricians of the first half of the eighteenth century who devoted most 
attention to it. The last-named observer was the first to point out the 
causal relation which rhachitis bears to many cases of pelvic deformity. 

Important contributions to the subject were made by Smellie. In 
his treatise on “The Theory and Practice of Midwifery,” published in 
1752, is to be found an excellent description of the normal pelvis, as well 
as of the more usual varieties of deformity to which it is subject. He 
also laid down practical rules for the estimation of the degree of con¬ 
traction, carefully described the mechanism of labor in such cases, and 
gave excellent pictures showing the influence exerted by the contracted 
pelvis upon the foetal head. 

Baudelocque (1746-1810) contributed largely toward the develop¬ 
ment of our knowledge of the subject, as he devoted particular atten¬ 
tion to the diagnosis of the condition in the living woman, and showed 

780 





FREQUENCY 


781 


that it could be detected by measuring the distances between certain 
external bony points of the pelvis by means of a pair of calipers. He 
was the first to describe the external conjugate, which is now generally 
known by his name, and taught that by deducting 3 inches from it the 
length of the conjugata vera could be readily and accurately estimated. 

At the same time Cf. W. Stein, in Germany, did good work upon 
somewhat similar lines and devised a pelvimeter for the direct mensura¬ 
tion of the conjugata vera. 

The real foundation, however, for our modern doctrine was laid by 
Michaelis and Litzmann. The former was Professor of Obstetrics in the 
University of Kiel from 1843 to 1850, and during that time carefully 
measured the pelvis in 1,000 consecutive cases of labor. He designated 
as contracted all pelves in which the conjugata vera measured 8.75 
centimeters or less, and found 72 such cases in his series, a percentage 
of 7.2. After his death he was succeeded by Litzmann, who continued 
the work, and soon reported accurate measurements based upon a second 
series of 1,000 cases. He advanced the definition which is given at the 
beginning of the present chapter, and placed the upper limit at a con¬ 
jugata vera of 10 or 9.5 centimeters, according as the pelvis is generally 
contracted or flat, respectively. Judged by these criteria he found 14.9 
per cent, of abnormal pelves, and estimated that had Michaelis employed 
the same standard his percentage would have been 13.1. 

LitzmamPs definition and criteria have been adopted throughout the 
world, and since the appearance of his work scientific obstetricians have 
devoted an increasing amount of attention to the subject. To mention 
all who have added materially to our knowledge would be equivalent to 
writing the history of obstetrics for the past fifty years; but Naegele, 
Kilian, Schauta, and Breus and Kolisko may be cited as among the most 
important contributors. 

Frequency.—In this country and in England very few statistics are 
available upon which to base accurate statements as to the frequency 
of contracted pelves, but in Germany and France many of the large 
lying-in hospitals supply valuable data. The incidence varies consider¬ 
ably in different countries, and even in various parts of the same coun¬ 
try. Thus, as is shown by the following table, it ranges from 8 to 24 per 
cent, in various German clinics. 


Goenner (Basel). 

Pfund (Munich). 

Fuchs (Erlangen). 

Kottgen (Bonn). 

Litzmann (Kiel). 

Muller (Berne). 

Weidenmiiller (Marburg)- 

Baisch (Tubingen). 

Leopold (Dresden). 


observed 

7.9 

per cent, in 2,433 

cases, 

< i 

9.5 

“ “1,199 

6 C 

L C 

11.43 

“ “1,766 

c c 

C i 

13.45 

“ “2,000 

(( 

i < 

14.9 

“ “1,000 

i ( 

C ( 

16 

“ “1,177 

i c 

c c 

18.7 

“ “3,224 

i ( 

i ( 

24 

“ “3,375 

(< 

< i 

24.3 

“ “2,415 

i c 


The statistics from the Austrian Empire seem to indicate a lesser 
frequency than in Germany, as is shown by the following table: 


Ludwig and Savor (Vienna).. 

Pawlik (Prague). 

Burger (Vienna). 


observed 3.84 per cent, in 50,621 cases. 

“ 7.8 “ ‘‘ 29,615 “ 

10.4 “ “ 49,397 “ 






















782 


CONTRACTED PELVIS 


Statistics based upon large series of cases are not available for 
France. Commandeur, however, places the incidence at 15 to 20 per 
cent., and states that it is Pinard’s belief that it has been greatly lowered 
since the last years of the nineteenth century following the introduction 
of more rational methods of infant feeding. 

Fancourt Barnes, in 1897, reported that only 0.5 per cent, of con¬ 
tracted pelves were observed in 38,065 cases of labor in London. In 
view of the fact, however, that every year many cesarean sections are 
performed in that city for this indication, it would appear probable that 
his figures in no way represent the true condition. 

It has been a matter of general belief that contracted pelves are 
very rare in America, and Dewees stated in 1824 that he had observed 
only three cases in his large experience. Lusk held a similar opinion, 
and said that rhachitis is rarely, and osteomalacia never, observed among 
native American women. We owe to Reynolds the first statistical state¬ 
ment upon the subject. In 1890 he reported that he had observed 1.34 
per cent, of contracted pelves in 2,227 women delivered in Boston. His 
figures, however, gave a false idea of the frequency of the condition; 
since he measured the pelvis only when operative interference was re¬ 
quired. Had he also taken into account the cases in which labor 
terminated spontaneously, he would, in all probability, have reported a 
frequency of 6.8 per cent. Flint, in 1897, observed 8.46 per cent, of 
contracted pelves in 10,233 consecutive patients delivered by the Society 
of the New York Lying-in Hospital. 

Since the opening of the lving-in department of the Johns Hopkins 
Hospital, it has been our rule to measure both externally and internally 
the pelvis of every pregnant woman coming into our hands. In 1899 I 
reported that we had met with 131 contracted pelves in the first 1,000 
women delivered. 

In 1911 I analyzed the conditions obtaining in 6,052 patients 
who had been delivered at term—3,491 white and 2,561 black. For 
the entire series, the incidence of the usual types of contracted pelvis 
was 18.5 per cent., but a pronounced difference was noted in the two 
races: 7.7 per cent occurring in the white, as compared with 33.2 per 
cent, in the black women. Furthermore, in the last 2,215 patients of 
the series the dimensions of the inferior strait were also measured, and 
all pelves were designated as “funnel” in which the distance between 
the tubera ischii measured 8 centimeters or less. Judged by this cri¬ 
terion 6.1 per cent, of the patients presented outlet contractions, but, 
in contrast to the contractions involving the superior strait, no difference 
was noted between the two races—the exact incidence being 5.9 and 
6.4 per cent, in the white and black women, respectively. 

Accordingly, in my service contraction of the pelvic inlet occurs 
nearly five times more frequently in black than in white women, while 
funnel pelves are equally frequent in the two races. In other words, 
every thirteenth white and every third colored woman in Baltimore 
has a typical contracted pelvis; while, in addition, every sixteenth 
woman in either race has a funnel pelvis. Hence, it is evident that 






METHODS OF DIAGNOSIS 


783 


no one can practice obstetrics without frequently encountering such 
conditions. 

As will be explained in detail later, the preponderance of the usual 
types of contracted pelvis in colored women is due to the prevalence of 
rickets, and to the general physical degeneration which seems to overtake 
members of that race who live long in large cities. That labor is not 
more disastrous to them is due to the fact that their children are smaller 
and have softer heads than white children, as was demonstrated by my 
former assistant, T. F. Higgs. 

That contracted pelves are not limited to civilized peoples is indi¬ 
cated by the observations of Emmons and Acosta-Sison. The former 
studied the pelves of 217 American Indian squaws and found that 
29 per cent, were abnormal; while the latter has stated that in Filipino 
women the pelvic conditions are practically identical with those observed 
in the American negress. 


Methods of Diagnosis.—It is essential that the obstetrician be able to 
determine the existence and extent of the contraction before the onset of 
labor, in order that he may, as far as possible, decide in advance upon the 
proper treatment to be instituted in each case. With this in view, 
accurate pelvic mensuration should constitute an integral part of the 
preliminary examination of the pregnant woman, and, in the present 
state of our knowledge, a physician who practices obstetrics without 
pelvimetry must be regarded as no better than one who treats diseases 
of the heart and lungs without the aid of auscultation and percussion. 

At the preliminary examination, four to six weeks before the ex¬ 
pected time of confinement, the physician should neglect no means of 
obtaining all possible data bearing upon the case. Generally speaking, 
large, well-built women are likely to have normal, and undersized women 
contracted, pelves; but this rule by no means always holds good, and 
it is not unusual for examination to disclose some abnormality in the 
former and normal pelves in the latter. 

The gait of the patient should be carefully noted, since the existence 
of a limp or some peculiar way in which the feet are placed upon the 
floor may serve to direct attention to the possibility of a pelvic deformity. 
Marked abnormalities of the spinal column—kyphosis or lordosis—are 


also suggestive, and even slight degrees of spinal curvature should not 
be overlooked, as they are frequently of rhachitic origin. The more 
usual signs of rhachitis—deformities of the extremities, the characteris¬ 
tically shaped head, and the rhachitic rosary—should always be looked 
for. Likewise, inquiry should be made as to the age at which the patient 
first learned to walk, and if she is found to have been backward in this 
respect the possibility of a rhachitic pelvis should be borne in mind, 
even though the usual external manifestations of the disease may be 

lacking. 

If the patient has already borne children she should be questioned as 
to the course of previous labors, and the history of any serious difficulty 
should always suggest the possibility of an abnormal pelvis. On the 
other hand, a negative history is by no means so valuable, as it is a well- 
known fact that in moderate degrees of pelvic contraction the first labor 






784 


CONTRACTED PELVIS 


may be relatively easy, while each successive one becomes more difficult. 
In primiparous women a pendulous abdomen, or the failure of engage- 
ment of the head in the last month of pregnancy, should always be 
regarded as evidence of the existence of a disproportion between the 
child’s head and the pelvis, until careful examination shows that such 

is not the case. 

Pelvimetry .—While the above-mentioned conditions are of value m 
suggesting the possibility of pelvic deformity, accurate information as 

to its existence and extent can be obtained only by measuring the pelvis. 

For • this purpose external and 

internal pelvimetry are employed, 
according as the measurements are 
taken from the surface of the body 
or through the vagina. As has 
already been said, Baudelocque was 
the first to insist upon the impor¬ 
tance and value of the former, and 
invented the first pelvimeter, which 
consisted of a pair of calipers or 
compasses provided with a scale to 
indicate the extent to which they 
are opened. Innumerable instru¬ 
ments of this kind have since been 
devised, but, although most of them 
give satisfactory results, before buy¬ 
ing one it is always well to see that 
the blades are sufficiently curved to 
allow them to span the thighs of 
stout patients. Thus, BudiiTs pelvi¬ 
meter (Fig. 530), which can readily 
he carried in the pocket, gives satis¬ 
factory results in the majority of 
cases; but it cannot be used to measure the external conjugate in stout 
women, owing to the slight curvature of its blades. I usually employ 
the instrument devised by E. Martin (Fig. 531). 

(a) External Pelvimetry .—The ordinary measurements are four in 
number: the distance between the anterior superior spines of the ilium, 
between the crests of the ilium, between the heads of the trochanters, and 
between the depression beneath the spinous process of the last lumhar 
vertebra and the anterior surface of the symphysis pubis. Normally 
these measure 26, 29, 32, and 21 centimeters respectively in the living 
woman. Naegele suggested certain other measurements, which, as a 
rule, are not employed unless one suspects the existence of an obliquely 
contracted pelvis. 

When the pelvis is to be measured externally, the patient should lie 
upon a bed or table with her abdomen and hips either hared or covered 
only by a thin chemise. The legs and upper portions of the body should 
not be exposed. In order to make the first three measurements, the 
physician should face the patient. He then grasps the tips of the pelvim- 



Fig. 530. —Budin’s Fig. 531. —Martin’s 
Pelvimeter. Pelvimeter. 









METHODS OF DIAGNOSIS 


785 



eter between the thumb and second finger of each hand, and, having 
located the outer edges of the anterior superior spines with the index 
fingers, presses the tips of the pelvimeter upon them as closely as pos¬ 
sible, the distance between 
them being indicated on the 
scale of the instrument. 

In measuring the dis¬ 
tance between the iliac 
crests, the most widely sepa¬ 
rated portions are located, 
and the tips of the pelvi¬ 
meter applied to their outer 
edges. In taking these 
measurements, it should be 
borne in mind that the iliac 
spines and crests present an 
outer and inner lip and an 
intermediate ridge, and that Fig. 532 .—Method of Holding Pelvimeter. 
the distance between the 

outer lips is 1.5 to 2.5 centimeters greater than that between the inner 

lips. 


Fig. 



533.—Measuring the Distance between the Anterior Superior Spines. 


















786 


CONTRACTED PELVIS 



Fig. 534.—Measuring the External Conjugate. 

cian. As a rule, the spine of the last lumbar vertebra is quite prominent, 
and is readily found by palpating and counting the spinous processes 
from above downward. Immediately beneath it is a slight depression, 
which forms the posterior extremity of the diameter to be measured. 
Into this one tip of the pelvimeter should be inserted and held firmly 
in place, while the other hand seeks the upper margin of the symphysis 
pubis, and firmly applies the other tip of the pelvimeter to it. The dis¬ 
tance separating them is then read off on the scale. 

In stout women some difficulty may be experienced in locating the 
posterior extremity of this diameter, owing to the fact that the spinous 
process of the last lumbar vertebra cannot be identified. This difficulty 
can usually be obviated in the following manner: The depressions mark¬ 
ing the attachment of the fascia to the superior posterior spines of the 
ilium, which are usually clearly visible, are located, and the ball of the 


In determining the distance between the trochanters , the patient’s 
legs having been brought into close apposition, the examiner carefully 
palpates the upper portion of the thighs until the most prominent 
points of the trochanters are felt on either side, the tips of the pelvim- 
eter are then firmly pressed against them, so that they come into the 
closest possible contact with the bones, after which the measurement is 
read off on the scale. 

The external conjugate, or Baudelocque’s diameter , extends from the 
depression just beneath the spine of the last lumbar vertebra to the 
anterior and upper margin of the symphysis pubis. For this measure¬ 
ment, the woman should lie on her side with her back toward the physi- 





























METHODS OF DIAGNOSIS 


thumb applied over one and that of the second finger ov 
index finger then seeks the spine of the last lumbar ve 
usually lie about 2.5 centimeters above the line joinim 
second finger, or at the apex of a four-sided space—M 
boid whose upper and lower margins are formed by the 
sacrospinalis and gluteus muscles respectively. 

I he Value of External Pelvimetry. —Baudeloeque, in d 
external conjugate, stated that by deducting 3 inches from 
of the true conjugate could be accurately estimated, 
opinion upon the fact that he had rarely ob¬ 
served a difference of more than 1 or 2 lines v ' 

between the estimated and the actual conjugata 
vera in 30 odd cases which he had measured 
during life and at autopsy. Later experience ‘ 
however, has shown that these conclusions we] 
erroneous, and that the length of the externa 
conjugate gives a very imperfect idea of tha 
of the conjugata vera, since several modifying 
factors may exist. Thus, the amount to be de¬ 
ducted varies with the thickness of the sacrum 
and the symphysis pubis, and also depends, to 
a great extent, upon the elevation of the promon¬ 
tory of the sacrum and the length of the spinous 
process of the last lumbar vertebra. Unfortu¬ 
nately, these factors cannot be accurately esti 
mated in the living woman, and Skutseh has 
shown that in 100 pelves examined by him the 
difference between the length of the external and 
of the true conjugate varied from 5.5 to 10 
centimeters. Baisset arrived at similar conclu¬ 
sions after studying 120 dried pelves; and I have 
in my possession two specimens whose true conju¬ 
gates are of equal length, but whose external 
conjugates show a difference of 5 centimeters. 

Although the measurement of the external 
conjugate does not give accurate information 
concerning the length of the conjugata vera, it 
nevertheless enables us to draw certain important 
conclusions. Thus, generally speaking, when the 
former measures between 20 and 21 centimeters, the conjugata vera wl 
rarely be found to be shortened; when, however, it measures between 
18 and 19 centimeters, the conjugata vera is shortened in about one-half 
of the cases; and when it is below 17 centimeters pelvic contraction is 
almost uniformly present. 

It was formerly believed that one could form a fairly accurate esti¬ 
mate of the length of the transverse diameter of the superior strait by 
making certain deductions from the distances between the anterior supe¬ 
rior spines and between the crests of the ilium. The incorrectness of 
this conclusion, however, was first demonstrated by Scheffer, who showed 


Fig. 535.—R .. 
Rhomboid' (Sti. 


CONTRACTED PELVIS 


mse diameter of the superior strait may be of the same 
elves, while at the same time the distances between the 
/ by as much as 3.3 centimeters. This source of error 
iat part upon the angle which the iliac fossa forms with 
.he innominate bone, and the extent to which its anterior 
^*ed out. 

stance between the trochanters is the least valuable of all the 
easurements, as its length depends, to a great extent, upon 
hich the neck of the femur forms with its shaft; and as a 
its shortening, unless very marked, does not indicate a cor- 
°^rease in the transverse diameters of the pelvic cavity. 

'01, demonstrated that external pelvimetry alone gave 
lea concerning the existence of contracted pelvis, 
external diameters in 100 cadavers, he compared 
e pelvic cavity when measured directly, and found 
mer indicated that nearly all of the pelves were 
proved that such was the case in only 22 instances, 
bear out his conclusions; as the use of the external 
w r ould indicate the presence of contracted pelvis in 
1 colored women, as compared with only one-third 
al pelvimetry. 

spite many possible inaccuracies, the external meas- 
siderable value, in that they serve to indicate with 
e type of pelvis with w r hich one has to deal. Nor- 
•tween the spines is 2.5 to 3 centimeters less than 
ts; but in the rhachitic pelvis, owing to the flaring 
is proportion becomes deranged, and the two meas- 
te one another, the former frequently being equal 
exceeding the latter. If, however, both measure- 
tbly below the normal, but preserve their usual rela- 
..;r, and at the same time the external conjugate is also 
shortened, it is permissible to conclude that the entire 
below normal in all its diameters, or, in other words, is 
airracted. 

y rule to employ external pelvimetry at the preliminary exam- 
ur to six weeks before the expected date of confinement. If 
•urements are approximately normal, the patient being a prim- 
and the child’s head deeply engaged in the pelvic cavity, internal 
uisuration is not practiced. But if the head is not engaged, internal 
pelvimetry should be resorted to, no matter how normal the external 
pelvic measurements may be. 

( ' ) Internal Pelvimetry .—In the majority of abnormal pelves the 
most marked deformity affects the anteroposterior diameter of the supe¬ 
rior strait, and as a consequence we are especially anxious to ascertain 
the length of the conjugata vera. Unfortunately, this cannot be meas¬ 
ured directly in the living woman, except by means of especially con¬ 
structed instruments, concerning whose accuracy there is no unanimity 
oi opinion, and consequently in practice it is estimated after measuring 
the diagonal conjugate—the distance from the promontory of the sacrum 




j METHODS OF DIAGNOSIS 789 

( to the lower margin of the symphysis pubis—and making a certain de- 
e duct ion from it. This method was introduced by Smellie, and still fur- 
m ther elaborated by Baudelocque. 

Measuring the Diagonal Conjugate .—For this purpose the patient 
rj should be placed upon an examining table with her knees drawn up. 
| If this cannot be conveniently arranged, she should be brought to the 
e edge of the bed and a firm pillow placed beneath her buttocks. Two 
J fingers are introduced into the vagina, and, before measuring the diagonal 
; conjugate, the motility of the coccyx is determined and the anterior 
. surface of the sacrum is palpated. The first is ascertained by seizing 



the coccyx between the fingers in the vagina and the thumb externally 
and attempting to move it to and fro. The anterior surface of the sa¬ 
crum is then methodically palpated from below upward, and its vertical 
and lateral curvature noted. In normal pelves only the last three sacral 
vertebrae can be felt without pushing up the perineum, whereas in 
markedly contracted varieties the entire anterior surface of the sacrum is 
readily accessible. 

Ordinarily, in order to reach the promontory of the sacrum, the 
elbow must be depressed and the perineum forcibly pushed upward by the 
knuckles of the third and fourth fingers, while the index and second 
fingers are held firmly together and directed upward in the direction of 
the umbilicus. The promontory is felt by the tip of the second finger 
as a projecting bony margin at the base of the sacrum. With the finger 

















790 


CONTRACTED PELVIS 



closely applied to its most prominent portion, the hand is elevated until 
the radial surface of the index finger is brought into close contact with 
the pubic arch. This point is then marked by the nail of the index 

finger of the other hand, 
after which the fingers are 
withdrawn from the vagina 
and the distance between 
the mark and the tip of 
the second finger is meas¬ 
ured (Figs. 536 and 537). 
This ‘represents the diag¬ 
onal conjugate, from which 
the true conjugate is esti¬ 
mated by deducting 1.5 
to 2 centimeters, according 
to the height and inclina¬ 
tion of the symphysis 
pubis. 

In this method the 
problem consists in esti¬ 
mating the length of one 
side of a triangle, the con- 
jugata vera; the other two 
the diagonal conjugate and the height of the symphysis pubis—being 
known. Were we able to measure satisfactorily the angle formed between 
the symphysis and conjugata diagonalis, the exact length of the true 


Fig. 537. —Measuring the Length of Diagonal 
Conjugate upon the Fingers. 



Fig. 538. 



Fig. 539. 


Figs. 538, 539.— Diagrams Showing Variations in Length of Diagonal Conjugate 
ependent upon the Height and Inclination of the Symphysis Pubis. 


conjugate could readily be ascertained by the ordinary rules of trigo¬ 
nometry. Unfortunately, this cannot be done accurately in the living 
woman, but for practical purposes it suffices to estimate the length of the 












METHODS OF DIAGNOSIS 


791 




diagonal conjugate as just described, deducting 1.5 centimeters from it if 
the pubis is low and slightly inclined, and 2 centimeters if it is high 
and has a marked inclination. The rationale of this is clearly shown 
in Figs. 538 and 539. The length of the diagonal conjugate also varies 
according to the position of the promontory, being longer when it is 
elevated, and vice versa (big. 540). Van der Hoeven (1912) has pointed 
out the fallacies involved in indirect menstruation, and holds that they 
aie so great as almost to destroy its usefulness. 

Since the time of G. W. Stein (1772), numerous instruments have 
been devised for the purpose of measuring the conjugata vera directly; 
but unfortunately majority of them, while theoretically correct, are 
practically useless on account of the difficulty of their application. De¬ 
scriptions and illustrations of 
many of them are to be found in 
Skutsch’s excellent monograph. 

Skutsch, in 1886, devised a 
pelvimeter by which the conju¬ 
gata vera could be indirectly, 
though accurately, measured 
(Fig. 542). Hirst more recently 
described a simple device for the 
same purpose. Both of these 
instruments give fairly satisfac¬ 
tory results when properly used, 
but their employment is usually 
so painful to the patient as to 
require the administration of an 
anesthetic. 

Since 1904 renewed interest 
has been manifested in the direct 
mensuration of the conjugata 
vera, and Bylicki, Gauss, Zange- 
meister, and others have devised instruments for the purpose. In the 
hands of their inventors such pelvimeters have proven satisfactory, but 
others have found that their employment gives no more accurate results 
than can be obtained by the old manual method. I have not been able 
to use the instruments of Gauss or Zangemeister in primiparous women, 
except under anesthesia; and, even when the vaginal outlet is so relaxed 
that they can be employed without undue pain, the results obtained 
have not seemed especially accurate, except when the degree of con¬ 
traction was very pronounced. 

Neumann and Ehrenfest, in 1900, described a complicated instru¬ 
ment—the pelvigraph —by means of which the contour of the anterior 
and posterior walls of the pelvis can be graphically outlined, whence the 
exact length of the various anteroposterior diameters can be readily ascer¬ 
tained. This instrument gives excellent results, but is too complicated 
for use outside of a special hospital. 

Measuring the Transverse Diameter of the Superior Strait .—This 
diameter cannot be measured directly in the living woman, and, as a 



Fig. 540.—Diagram Showing Effect of 
Position of Promontory of Sacri m 
upon the Length of the Diagonal 
Conjugate. 






792 


CONTRACTED PELVIS 




Fig. 542. —Measuring Conjugata Vera with Skutsch’s Pelvimeter. 












METHODS OF DIAGNOSIS 


797 



by Ivlien as the posterior saggital of the outlet, and should be measured 
whene\ er the transverse diameter measures 8 centimeters or less. This 

however, will be considered in greater detail under the heading of Funnel 
Pelvis. 

Use of X-rays. —After the discovery of the Pontgen ray and the 
demonstration of the various uses to which it might be put, it was 
thought possible that it might also afford a valuable method of investi¬ 
gating the shape and size of the pelvis. Budin and Varnier, in 1897, 






Fig. 549. —Diagram Showing Williams’ Modification of Breisky’s Method of 
Measuring Anteroposterior Diameter of Outlet. X l / z . 

reported their experience with it, and showed that, while it often gave 
an excellent general idea of the shape, the ideas as to size obtained by 
it were erroneous. A comprehensive review of the literature upon the 
subject was given by Miillerheim in 1898. 

All ordinary radiograms of the pelvis give distorted ideas in regard 
to its dimensions, owing to the fact that, as the symphysis and promon¬ 
tory of the sacrum lie in different planes, one part of the superior strait 
is enlarged out of all proportion to the other, according as the picture 
is taken with the woman lying on her back or abdomen, as the case 
may be. Such defects make it impossible to attempt to utilize the radios 
giaph for purposes of mensuration. Bouchacourt suggested that this 












798 


CONTRACTED PELVIS 


might be obviated by placing a rectangular metal frame about the 
woman’s hips, more or less corresponding to the plane of the superior 
strait, each side of the frame being marked by indentations 1 centimeter 
apart. When the picture was taken these would also be reproduced, and 
upon connecting the corresponding points upon the four sides of the 
picture a definite idea could be obtained as to the dimensions of the 
superior strait. This method has been employed by E abre for years, and 
has given satisfactory results. The method described by Thoms in 1922 
is useful and interesting, but suffers from the defect that it is not avail¬ 
able after the middle of pregnancy, when information is most desired 
by the obstetrician. 

Classification of Contracted Pelves. —For the first classification of ab¬ 
normal pelves we are indebted to Deventer, who distinguished three 
groups: too large, too small, and too flat pelves. 

Most recent attempts at classification have been based upon the shape 
of the pelvis, without taking into consideration the etiological factors 
which lead to its production. This method was adopted by Michaelis, 
and reached its greatest perfection in Litzmann’s hands. The former 
thoroughly realized its inherent defects and regretted that other methods 
of classification could not be employed. Kilian, Busch, and Siebold had 
previously recognized the necessity of taking into account the etiological 
factors which are concerned, but their knowledge was too meager to 
permit of such a course. 

It was not until 1889 that Schauta was able to suggest a fairly satis¬ 
factory etiological classification, which soon obtained general acceptance, 
although it was still far from ideal. Tarnier and Budin, in their 
treatise issued in 1898, followed somewhat similar lines. Breus and 
Kolisko do not consider that either is perfectly satisfactory, and have 
suggested a substitute for them. 

Owing to the fact that our knowledge of the fundamental factors 
underlying the production of many forms of abnormal pelves is still 
very meager, and occasionally entirely lacking, it is apparent that at the 
present time no etiological classification can be perfectly satisfactory, 
though from a practical point of view the one employed by Tarnier and 
Budin would seem to approach it. In the following chapters I shall 
employ a combination of the classification of the latter and that of 
Schauta, although I am well aware that it is far from ideal. 


LITERATURE 


Acosta-Sisson. Pelvimetry and Cephalometry among Filipinos. Philippine J. 

Sci., 1914, ix, 493-497. 

Arantius. See Chapter I. 

Baisch. Reformen in der Therapie des engen Becken. Leipzig, 1907. 

Baisset. De la mensuration externe du bassin. These de Lyon, 1901. 

Barnes. Internat. Gyn. Congress, Geneva, 1896. Zentralbl. f. Gvn., 1896, xx, 
1089. 


Baudelocque. L’art des aecouchements. Nouvelle ed., 1789 t. i., 
Bouchacourt. Be la radiographie du bassin de la femme adulte/ 
1900, v, 320-351. 


76-90. 

L ’obstetriqi e. 


LITERATURE 


799 


Breisky. Beitrage zur geburtshiilfliclien Beurtheilung der Verengerungen des 
Beckenausganges. Wiener med. Jahrb., 1870, xix. 

Bretjs und Kolisko. Die pathologischen Beckenformen. Wien, 1900, Tkeil I. 
Budin. Statistiques de la Maternite de Paris. L ’obstetrique, 1896, iii, 134. 
Photographie par les rayons x d’un bassin de Naegele. L’obstetrique, 1897, ii, 
499. 

Busch. Geburtskunde, Berlin, 1849. 

Bylicki. Ueber eine Methoden den geraden Beckeneingangsdurclimesser mittelst 
einer Skala von Winkelhebeln unmittelbar zu messen. Monatsschr. f. Geb. ii. 
Gyn., 1904, xx, Erganzungsheft, 441-452. 

Commandeur. Viciatious pelviennes. In Bar, Brindeau et Chamberlent, La 
pratique de 1 ’art des accouchements. 1914, ii, 184-346. 

Deventer. Operationes chirurgicae novum lumen exhibentes obstetricanibus, 1701. 
Dewees. A Compendious System of Midwifery. Philadelphia, 1824. 

Dionis. Traite general des accouchements, etc. Paris, 1718. 

Emmons. A Study of the A T ariations in the Female Pelvis, etc. Biometrika, 
1913, ix, 34-57. 

Fabre. Radiographie du bassin. Precis d’obstetrique, 1922, III Ed., 201-211. 
Flint. Deformed Pelves. Rep. of Soc. of the Lying-in Hosp., New York, 1897, 
258-271. 

Fuchs. Statistik der in den letzten 10 Jahren in der Erlanger Universitats- 
Frauenklinik vorgekommenen engen Becken. D. I., Wurzburg, 1899. 

Gauss. Die unmittelbare Messung der Congugata obstetricia. Zentralbl. f. Gym, 
1906, 763-766. 

Goenner. Zur Statistik des engen Beckens. Zeitschr. f. Geb. u. Gyn., 1882, vii, 

314. 

Ein hundert Messungen weiblicher Becken an der Leiche. Zeitschr. f. Geb. u. 
Gyn., 1901, xliv, 308-325. 

Hirst. American Text-Book of Obstetrics, 1897, 498-510. 

Kilian. Die Geburtslehre yon Seiten der Wissensehaft und Kunst dargestellt. 
Frankfurt, 1840. 

Klien. Die geburtshiilfliche Bedeutung der Verengerungen des Beckenausgangs. 

Volkmann’s Sammlung klin. Vortrage, N. F., 1896, Nr. 169. 

Knapp. Bericht iiber 105 Geburten bei engen Becken aus den Jahren 1881-’95. 

Archiv f. Gyn., 1886, xl, 489-586. 

Kottgen. Zur Statistik des engen Beckens. D. I., Bonn, 1895. 

Leopold (Franke). Enges Becken und spontane Geburt. Arbeiten aus d. konigl. 

Frauenklinik in Dresden, 1895, ii, 29-48. 

Litzmann. Die Formen des Beckens. Leipzig, 1861. 

Die Geburt bei engen Becken. Leipzig, 1884. 

Ludwig und Savor. Klin. Bericht iiber die Geburten bei engen Becken in dem 
Zeitraum, 1878- ’92. Bericht aus der II. geb. gyn. Klinik in Wien, R. Chrobak, 
1897, 120-394. 

Lusk. The Science and Art of Midwifery. Fourth ed., 1895. 

Mauriceau. Observations sur la grossesse et 1 accouchement des femmes. T\ouv. 
ed., 1738. 

Michaelis. Das enge Becken. Leipzig, 1851. 

de la Motte. Traite complet des accouchements naturels, etc. Aouv. ed., Leiden, 
1729. 

Muller. Zur Frequenz und Aetiologie des allgemeinen verengten Beckens. 
Archiv f. Gyn., 1880, xvi, 155. 

MTtllerheim. Verwerthung der Rontgen Strahlen in der Geburtshiilfe. Deutsche 
med, Wochenschr., 1898, xxiv, 619-621. 






800 


CONTRACTED PELVIS 


Naegele. Das weibliche Bccken, etc. Carlsruhe, 1839. 

Das schrag verengte Bccken, etc. Mainz, 1839. 

Neumann und Eiirenfest. Eine neue Metkode der inneren Beckenmessung an 
der lebenden Frau. Monatssckr. f. Geb. u. Gyn., 1900, xi, 23/ -253. 

Par£. See Chapter I. 

Pawlik. Internal. Gyn. Congress, Geneva, 1896. Zentralbl. f. Gyn., 1896, xx, 
1090. 

Pfund. Aerztl. Intelligenzblatt, 1895, xxxii, 247. 

Pinard. Fonctionnement de la maison d ’accouchement Laudelocque. For various 
years. 

Puzos. Traite des accouckements, etc. Paris, 1749. 

Reynolds. The Frequency of Contracted Pelves. Trans. Am. Gyn., Soc., 1890, 
xv, 367-377. 

Riggs. A Comparative Study of White and Negro Pelves, etc. Johns Hopkins 
Hospital Reports, 1904, xii, 421-454. 

Schauta. Die Beckenanomalien. Muller’s Handbuch der Geb., 1889, ii. 

Scheffer. Ueber das Verhaltniss des Abstandes der Spinae und Cristae ilium 
zu dem des Querdurchmcsser des Beckeneinganges. Monatsschr. f. Geburtsk., 
1868, xxxi, 299-309. 

Sellheim. Zur Lehre vom engen Becken. Beitrage zur Geb. u. Gyn., 1906, ix, 
253-312. 

Siebold. Lehrbuch der Geburtshiilfe, 1854. 

Skutsch. Die Beckenmessung. Jena, 1886. 

Die praktisehe Verwerthung der Beckenmessung. Deutsche med. Woch., 1891, 
Nr. 21. 

Smellie. Treatise on the Theory and Practice of Midwifery, with Collection of 
Cases. Eighth ed., London, 1774. 

Stein, G. W. Besclireibung des kleinen und einfachen Beckenmesser, etc. Kleine 
Werke zur prak. Geburtsh., Marburg, 1798, 135. 

Steinbrecher. Die Schiitzung der Transversa des Becken-eingangs nach Lohlein. 
Archiv f. Gyn., 1907, lxxxi, 433-450. 

Thoms. A Statistical Study of the Frequency of Funnel Pelves and the Descrip¬ 
tion of a New Outlet Pelvimeter. Am. J. Obst., 1915, lxxii, 121-132. 

Outlining the Superior Strait by Means of the X-ray. Am. Jour. Obst. & Gyn., 
1922, iv, 257-263. 

Van der Hoeven. Der Wert einiger Beckenmasse. Monatsschr. f. Geb. u. Gyn., 
1912, xxxv, 1-24. 

Varnier. Etude anat. et radiograpliique de la symphyse pubienne apres le sym- 
physeotomie. Comptes rendus de la soc. d’obst., de gyn. et de paed. de Paris, 
1899, i, 209. 

Wiedenmuller. Zur Statistik des engen Beckens. D. I., Marburg, 1895. 

Williams. Pelvimetry for the General Practitioner. Medical News, March 21, 
1891. 

Frequency of Contracted Pelves in Baltimore. Johns HopRins Hosp. Bulletin, 
1896, vii, 164. 

Frequency of Contracted Pelves in the First One Thousand Women Delivered in 
the Obstetrical Department of the Johns Hopkins Hospital. Obstetrics, 1899, 
i, Nos. 5 and 6. 

Frequency, ^Etiology and Practical Significance of Contractions of the Pelvic 
Outlet. Surg. Gyn. and Obst., 1909, viii, 619-638. 

The Funnel Pelvis. Am. J. Obst., 1911, lxiv, 106-124. 

Zangemeister. Beitrag zur Lehre vom engen Becken. Zentralbt. f. Gyn., 1922, 
1395-1406. 


CHAPTER XXXIY 


ANOMALIES DUE TO ABNORMAL MALLEABILITY OF THE PELVIC 

BONES 

FLAT NON-RHACHITIC PELVIS 

It is generally held that this is the most usual variety of pelvic de¬ 
formity occurring in white women, as it was noted in 43 per cent, of the 
contracted pelves described by Michaelis. Litzmann stated that its fre¬ 
quency, as compared with that of the rhachitic pelvis, was as 7 to 5. In 
my experience, however, the funnel and the generally contracted pelvis 
are the most usual abnormalities in white women, in whom the simple 
flat pelvis occupies the third place, but occurs extremely rarely in black 
women. 

The following table gives the relative incidence of the more common 
types of contracted pelvis in the two races, as observed at the Johns 
Hopkins Hospital in a series of 4,000 women delivered at full term— 
2,459 white and 1,541 hlack—in whom the diameters of the pelvic out¬ 
let were also measured (Case 2,000—6,957) : 


WHITE 

VARIETY OF PELVIS 

Total No. 

Incidence 

Percentage of 
Contracted 
Pelves 

Funnel. 

125 

5.1 

37.87 

*Generally contracted.. 

*130 

5.3 

39.39 

Simple flat. 

52 

2.1 

15.75 

Gen. cont. rhachitic.. . 

11 

0.4 

3.36 

Atypical. 

7 

0.3 

2.12 

Flat rhachitic. 

5 

0.2 

1.51 

Total. 

330 

13.4 

100.00 


BLACK 

VARIETY OF PELVIS 

Total No. 

Incidence 

Percentage of 
Contracted 
Pelves 

*Generally contracted.. 

*348 

22.9 

56.40 

Gen. cont. rhachitic... 

155 

10.0 

25.12 

Funnel. 

89 

5.8 

14.42 

Flat rhachitic. 

15 

1.0 

2.43 

Simple flat. 

7 

0.5 

1.14 

Atypical. 

3 

0.2 

0.49 

Total. 

617 

40.4 

100.00 


* Including generally contracted funnel pelves. 


In this series of patients, the simple flat pelvis occurred in 2.1 per 
cent, of the white and in 0.5 per cent, of the black women; and, upon 
omitting the outlet contractions, it represented 25 and 1.3 per cent, 
respectively, of the abnormal pelves in the two races. 

Most German authors confirm the statements of Michaelis and Litz¬ 
mann as to its frequency. On the other hand, Ahlfeld dissents from this 
view, holding that many of the pelves which have been designated as 
simple flat are really of rhachitic origin, and Tarnier and Budin state 

801 







































S02 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC EONES'l 

that only one-sixteenth of the abnormal pelves with which they met I 
could be attributed to other causes than rhachitis. 

This variety is frequently described as the pelvis plana Deventeri, ■ 
or simple flat pelvis, although it is doubtful whether Deventer ditferen- 1 
tiated between it and the rhachitic form. It was accurately described 
by Betschler in 1832, but Michaelis and Litzmann were the first to insist 
upon its importance and frequent occurrence. 

The characteristic feature of the flat non-rhachitic pelvis consists in 
a shortening of all the anteroposterior diameters of the pelvic cavity, 


Fig. 550. 



Fig. 551. 

Figs. 550-552. —Flat Non-rhachitic Pelvis. 



while the transverse measurements remain practically normal. 1 This 
condition is due to the fact that the entire sacrum approaches more 
nearly than normal to the symphysis pubis. At the same time it under- 

1 r ihe illustrations in the chapters on Contracted Pelves have been prepared 
with great care. The half-tone illustrations are exactly one-third natural size, 
and were drawn from photographs which were taken with the pelves as nearly as 
possible in the same position—that is, with the tip of the coccyx and upper 
margin of the symphysis pubis on the same horizontal level. Accordingly, the 
illustrations can be accurately compared. 

The diagrams of the superior strait and the sagittal sections through the pelvic 
cavity are one-sixth natural size, and are accurate to within one millimeter. The 
former were made by means of the camera with the plane of the superior strait 
at right angles to the horizon. The latter were made from tracings of casts of 
the pelvic cavity obtained by means of dental wax, and reduced by the pantograph. 


















FLAT NON-RHACHITIC PELVIS 


803 






goes a slight rotation about its transverse axis, as is shown by the fact 
that the contraction is always more marked in the superior than in the 
inferior strait. The degree of contraction is usually not very pronounced, 
and it is rare to find the conjugata vera measuring less than 8 centi¬ 
meters. In fact, whenever this limit is passed, the probability that one 
has to deal with a flat rhachitic pelvis should always be borne in mind. 

The sacrum does not present the characteristic features of rhachitis, 
and preserves its normal vertical and side to side concavity. Occa¬ 
sionally it may appear somewhat more delicately shaped than usual, 
and be narrower transversely. In such circumstances the transverse 
diameters of the pelvic cavity are also slightly decreased. 




In not a few pelves of this character the line of ossification between 
the first and second sacral vertebrae is more marked than usual, thus 
giving rise to a so-called second or accessory promontory. 

Etiology.—By many European authorities it is believed that the ap¬ 
proach of the sacrum to the symphysis results from the carrying of heavy 
burdens upon the back or head during early life, though such an explana¬ 
tion cannot apply in this country, where it is unusual for girls to carry 
heavy loads. In other cases the condition is attributed to the fact that 
the child was allowed to sit up at too early an age and for too long 
periods. 

Ahlfeld, Tarnier, and Breus and Ivolisko think that a part in the 
production of the deformity is played by rhachitis, which, they hold, 
may be present in a larval form without giving rise to its usual and 
characteristic manifestations. The latter state that the shortening of the 
conjugata vera is not so much due to a rotation of the sacrum as to the 
shortening of the iliac portion of the terminal length of the innominate 
bone; and, as they believe that this is usually the result of rhachitis, 
they consider that it aids materially in determining the etiology of the 
condition. 

Fehling and Schliepliake consider that this variety of pelvic anomaly 
is congenital in a certain number of instances, as they have shown that 
the pelves of newly born children may occasionally present a flattened 
appearance. In several cases studied by them the relation between: the 
conjugata vera and the transverse diameter of the superior strait as was 
100 to 145, 100 to 100, or 100 to 177, instead of 100 to 122, as is usually 
the case. In such circumstances the mechanical factors above alluded 
to could certainly not have come into play. 

Diagnosis.—The presence of a simple flat pelvis, as a rule, is readily 
detected. By external pelvimetry the distances between the spines and 
crests of the ilium, as well as between the trochanters, are found to be 
approximately normal, whereas Baudelocque ? s diameter is definitely 
shortened. On internal examination the diagonal conjugate is found to 
be shortened, though never to an extreme degree. In general, if it falls 
below 8 centimeters the pelvis does not belong in this category. The 
entire anterior surface of the sacrum appears to be nearer the symphysis 
than usual, but presents its normal curvatures. There is no widening 
of the transverse diameter of the pelvic outlet, as in the rhachitic form. 
The average measurements in 26 of my cases were: spines, 25.7; crests, 




804 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONE! 




27.8; trochanters, 30.5; Baudelocque’s diameter, 18; and diagonal con 
jugate, 10.7 centimeters. 


RHACHITIC PELVIS 


In many parts of Europe one of the most prominent factors in the 

production of contracted pelves in an ah 




cn 


CS — 


P* - *~ *.-■* t-* 

*• •- 


cc 


CM 


tdo 



fr/S' / 


lo 


VL —^ 



Sr is 


•vl 2# 




. * 


Fig. 553. —Section through 
Normal Epiphysis of Child 
(Spillman). 

cn., normal cartilage; cs., carti¬ 
lage cells arranged in parallel 
rows; cc., area of preliminary 
calcification; em., medullary 
spaces; o., osteoblasts; lo., 
osseous lamellae; rn., marrow'. 


normal softening of the bones in early lift 
resulting from rhachitis. In this countn 
the disease is observed comparatively rareh 
in white children, occasionally in coloret 
children inhabiting country districts, anc 
very frequently in those living in large cities 

In not a few cases the disease undergoes 
spontaneous cure, so that no trace of its 
existence can be discovered in later life: 
while in many instances permanent skeletal 
deformities result which are principally 
localized in the pelvis. Again, it is also 
not unusual to meet with women who to 
all appearances are quite normally formed, 
but whose pelves upon examination present 
rhachitic deformities. Khachitic pelves were 
noted in 0.64 per cent, of the white and 
11.03 per cent, of the black women in the 
tables given on page 801. Omitting outlet 
contractions, they constituted 8 and 32 per 
cent., respectively, of the abnormal pelves 
observed in the two races, thus showing that 
even in this country the disease is of marked 
importance from an obstetrical standpoint. 

Nature and Pathology of Rhachitis.— 
Before describing the various changes in the 
pelvis which may result from rhachitis, 
it will be well to consider briefly the nature 
and pathology of the disease. 

Unfortunately it is impossible to make 
clear-cut statements in this regard, more 
particularly as the work of Schmorl, of 
Recklinghausen, of Ogata, and of others 
tends to indicate that the difference between 
rhachitis and osteomalacia is nothing like so 
marked as was formerly believed. According 
to Kassowitz, Spillmann, and others, the for- 


mei is to be looked upon as an osteitis associated with an excessive forma¬ 
tion of osteoid tissue at the epiphyses and beneath the periosteum of the 
long bones, as well as in the flat bones of the skull and pelvis. The 
proliferation is accompanied by defective calcification of the newlv 















RHACHITIC PELVIS 


805 


formed tissue, Zweifel stating that only 18 to 24 per cent, of inorganic 
salts are present, as against 63 to 65 per cent, in normal bone. 

It is customary to distinguish three stages in the disease: conges¬ 
tion, softening, and progressive deformity or cure, as the case may be. 
In the first stage there is a great increase in vascularity, which is most 
marked at the union of the articular cartilages with the diaphyses of the 
long bones and also beneath the periosteum. In the former location the 
zone of preliminary calcification—Guerin’s line—is slightly thickened, 
and its lower portion adjacent to 
the newly formed spongy bone is 
perforated by numerous vascular 
loops. A similar condition may 
also be observed beneath the peri¬ 
osteum covering the long and the 
flat bones (Fig. 554). 

In the second stage, while 
Guerin’s line has become markedly 
thickened and very irregular, the 
vascular proliferation has advanced 
to a marked degree. Under the 
microscope the former is seen to 
be broken up in all directions by 
the rapidly growing vascular loops, 
which subdivide it into large num¬ 
bers of small irregularly shaped 
calcific areas. At the same time 
the formation of osseous tissue just 
beneath it proceeds in an irregular 
manner, calcification either failing 
to occur or taking place im¬ 
perfectly. In newly formed tissue, 
between the vascular loops and 
the narrow cavities, there is a considerable formation of osteoid tissue, 
with spindle- and star-shaped cells, which does not become ossified at all. 

To summarize these changes briefly, one may say that the growing 
end of the bone, instead of undergoing normal ossification, consists in 
great part of dilated capillaries which separate irregularly shaped masses 
of calcified cartilage from areas of connective tissue and imperfectly 
formed bone (Fig. 555). Similar changes take place under the perios¬ 
teum of the long and flat bones, so that the shaft of the bone soon 
becomes converted into a spongy tissue corresponding closely to that 

observed at the epiphysis. 

In the third period the process continues until death occurs; or, if 
recovery ensues—the usual outcome—there is a progressive decrease 
in vascularity, and the normal process of ossification is resumed, so that 
after a time the only trace of the disease is to be found in an atrophy 
of the bone, which is frequently associated with thickening and an in¬ 
creased porosity. It is therefore apparent that the bones become abnor¬ 
mally soft and yielding in the acute stages of the disease, so that if the 



Fig. 554.—Section through Epiphysis 
in Early Stages of Rhachitis (Spill- 
mann). 

c-s., cartillage cells arranged in parallel 
rows; tec., area of preliminary calcifi¬ 
cation; c., capillary; tc., unossified con¬ 
nective tissue. 













806 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 

child uses its extremities at the time, more or less marked deformity 
must result, depending upon the mechanical influences which are liable 
to modify the evolution of the infantile pelvis. Breus and Kolisko insist 
that practically no growth occurs during the acute stage of the disease, 
and, consequently, if it persists for any length of time, it must inevitably 
lead to atrophic changes, so that after recovery the bones are smaller and 
somewhat lighter than normal, even though they show no characteristic 
signs of deformity. 

Forms of Rhachitic Pelves.—As has already been said, the rhachitic 
type is one of the most frequently observed varieties of contracted pelvis, 



Fig. 555.—Section through Epiphysis in Advanced Stages of Rhachitis (Spillmann). 
tcc., area of preliminary calcification; cc., calcified cartilage; c, capillaries; 

tc., connective tissue. 

and in extreme cases presents the most marked deformities with which 
we are familiar, with the exception of those resulting from osteomalacia. 
Fortunately, however, the degree of contraction is usually not so pro¬ 
nounced, Tarnier having found that the conjugata vera measured less 
than 8.5 centimeters in only 14.4 per cent, of 1,020 rhachitic pelves. 

With the exception of the cases which are complicated by abnormali¬ 
ties of the vertebral column, or by deformities giving rise to a marked 
difference in the length of the limbs, rhachitic pelves are usually classified 
as follows: 

1. Flat rhachitic. 

2. Generally contracted, flat rhachitic. 

3. Generally and equally contracted rhachitic. 

4. Pseudo-osteomalacic. 












RHACHITIC PELVIS 


807 


1. Flat Rhachitic Pelvis .—In this variety the greatest contraction 
occurs in the anteroposterior diameter of the superior strait, while the 
transverse diameter is normal, or even slightly increased in length. 
Generally speaking, the pelvic hones are less dense in texture than 
usual, and frequently are delicate in form, though occasionally they 
may appear clumsy and swollen. Owing to the marked lordosis, which 
frequently results from rhachitis, the pelvic inclination, as a rule, is 
considerably increased. 

Most important changes are to be noted in the sacrum, which 



Fig. 556. 



Fig. 557. 



Fig. 556-558. —Flat Rhachtic Pelvis. 


differs from the normal in that it is broader from side to side, thinner 
from behind forward, shorter from above downward, and less concave on 
its anterior surface. The longitudinal axis of the bone is so altered 
as to form a greater angle with the conjugata vera, and consequently the 
promontory lies at a lower level than usual, appioaches the symphysis 
pubis, and encroaches markedly upon the area ol the supeiioi stiait. 

’ Usually the entire sacrum is sharply bent upon itself in the neighbor¬ 
hood of its third vertebra, so that its vertical concavity becomes markedly 
accentuated. Occasionally this does not occur, and in such cases the 








808 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 


sacrum may be quite straight from base to tip. At the same time the 
bodies of the individual vertebrae extend out beyond the level of their 
alae, thereby diminishing the lateral concavity of the sacrum, and 
generally converting it into a pronounced convexity. In the latter 
event the spinous processes project less far than usual beyond the poste¬ 
rior surface, which tends to become concave. 

As the upper part of the sacrum becomes displaced downward and 
forward, its posterior surface recedes from the superior posterior spines 
of the ilium, which approach one another more closely than in the 
normal condition, so that the posterior limb of the S-shaped curva¬ 
ture of the iliac crests becomes accentuated. 

Occasionally the anterior surface of the sacrum may be convex in 
both directions, and, when directed more vertically than usual, it may 
happen that the greatest convexity will coflespond to the region of the 
second and third sacral vertebrae. In this event the shortest diameter 
of the pelvis will be the anteroposterior of the plane of greatest pelvic 
dimensions, instead of the conjugata vera. Breus and Kolisko have 



Fig. 559. —Accentuation of Vertical 
Concavity of Sacrum in Rhachitis. 



Fig. 560. —Showing Obliteration of 
Vertical Concavity of Sacrum in 
Rhachitis. 


classified such pelves in a special group, and designate them as “middle 
flat.” In such cases the promontory of the sacrum is not displaced 
downward, and the condition is usually associated with assimilation. 

Occasionally the body of the first sacral vertebra is more markedly 
displaced forward than those below it, so that its lower margin projects 
beyond the general surface, and can be felt as a false, or double, prom- \ 
ontory. In such circumstances the distance between it and the sym¬ 
physis pubis may be shorter than the conjugata vera. The presence 
of a false promontory is usually indicative of the assimilation of an 
exti a veitebra to the sacrum, and its significance will be discussed when 
assimilation pelves are considered. 

The iliac bones are smaller and frequently more delicately shaped 
than usual, the vertical height of the pelvis as well as the length of the 
iliac crests being diminished. The iliac fossae are more concave, and 
frequently present a pronounced, sharp depression just in front of 
the sacro-iliac joint. As a result the anterior margin of the bone 
extends more vertically than usual, as is shown by comparing the slant 
of ^ ne j°iFiing the acetabulum and the anterior superior spine of 
















RHACIIITIC PELVIS 


809 


the ilium. At the same time the anterior portion of the hone flares out 
at the expense of the crest, so that the distance between the anterior supe- 

ii°r spines approaches that between the crests, and occasionally even 
exceeds it. 

The diminution in the size of the iliac bone is best appreciated by 
studying the “terminal length” (Figs. 27 and 28). Normally, its three 
component parts are practically of the same length, but in rhachitis 
the pubic portion retains its normal dimensions, the sacral portion is 
slightly shoitei than usual, while the iliac portion is greatly shortened, 



Fig. 562. Fig. 563. 

Figs. 561-563. —Flat Rhachitic Pelvis, Showing Double Promontory. 

and occasionally presents only a fraction of its normal length. Breus 
and Kolisko consider these changes almost pathognomonic’of rhachitis. 

In many cases the iliac bones bend just in front of the sacro-iliac 
synchondrosis, so that the iliopectineal line, instead of following a gentle 
curve, forms a sharp angle at that point, thus adding materially to 
the flattening of the superior strait. At the same time the acetabula 
are displaced forward, and thus come to lie upon the anterior instead 
of upon the lateral portion of the pelvic ring. 

The pubic arch is relatively wider than normal, and the tubera ischii 
may be so everted that the transverse diameter of the outlet appears to 
be exaggerated, and occasionally measures more than in the normal 












810 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 






pelvis. In view of the upward and backward dislocation of the tip oi 
the sacrum, the anteroposterior diameter of the outlet is also eithei 
relatively or absolutely increased in length. Consequently, in contrast 
with the flattened superior strait, the pelvic outlet appears wide and 

gaping, and in ex¬ 
treme cases may lx 
nearly twice as room) 
as the inlet (Fig. 
564, A and B). 

These changes ex¬ 
ert a decided influ¬ 
ence upon the shape 
of the pelvic cavity, 
the effect being most 
marked in the supe¬ 
rior strait, which may 
become oval, ren- 
iform, or even heart- 
shaped in outline, j 
according to the i 
degree of displace-1 
ment of the promon¬ 
tory of the sacrum, j 
The conjugata vera < 
is always shortened, ! 
while the transverse ; 
diameter seems to be 
enlarged, although 
this may be only rela¬ 
tive unless the pelvis \ 
be of large size. 
Owing to the ap- . 
proach of the ante- ] 
rior and posterior 
walls of the pelvis, 
the oblique diameters j 
of the superior strait 
are always shortened, 
as are also the sacro- 
cotyloid diameters. 

In occasional cases sharp exostoses may make their appearance 
upon the pubic crests, the iliopectineal eminences, or in front of the 
sacro-iliac synchondroses —pelvis spinosa. When such structures are not 
well covered by soft parts, they may lead to injury of the uterus at the 
time of labor. 


I' ig. 564. Generally Contracted Rhachitic Assimi¬ 
lation Pelvis. X } 3 . 

.4, anterior view; B, same pelvis seen from below showing 
relative widening of outlet. 


... Generally ( ontracted, Flat Rhachitic Pelvis .—It is in this variety 
of pelvis that marked degrees of contraction are often encountered, 
the conjugata vera sometimes being reduced to 3 or 4 centimeters. This 
pelvis corresponds closely to the ordinary flat rhachitic type, except 










RHACHITIC PELVIS 


811 


that the shortening applies to all its diameters instead of being limited to 
the conjugate vera. Notwithstanding the fact that all of the diameters 
of the inferior strait fall below the normal limits, the outlet usually 
appears abnormally large when compared with the generally contracted 
inlet (Fig. 564). 

The various component parts of the pelvis show a relative decrease 
in size, particularly marked in the sacrum, which may present a con¬ 
siderable* diminution in its transverse measurements. The small size 
of the pelvis in such cases may be due either to atrophic changes in 



Fig. 566. Fig. 567. 

Figs. 565-567. —Generally Contracted, Flat Rhachitic Pelvis. 


the bones resulting from the rhachitis itself, or to the fact that a 
primarily small pelvis had become affected with the disease. 

3. Generally Equally Contracted Rhachitic Pelvis .—This variety 
was first described by Michaelis, and according to most authors is 
observed but rarely. Muller, however, considers that not a few cases 
which were previously described as instances of simple, generally con¬ 
tracted (justominor) pelvis belong under this category, and my own 
experience, particularly in the negro race, confirms his observations. 

According to Litzmann, this type differs from the justominor pelvis 
in its ungainly and angular appearance, and in the maiked piominence 
of the pubic crests. The superior strait appears to be equally shortened 













812 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 


in all its diameters instead of merely flattened, while the rest of the 
pelvis presents indisputable signs of a past rhachitis, which is more 
particularly marked in the sacrum and in the eversion of the tubera 
ischii. 

4. Pseudo-osteomalacic Rhachitic Pelvis .—This variety is a mani¬ 
festation of the severest form of rhachitis, and is associated with the 
most marked degrees of contraction. As the name implies, the pelvis 
resembles one deformed by osteomalacia, the sacrum and lateral walls 
approaching one another so as to give rise to a very small, trefoil-like 
superior strait, the contraction also extending to other portions of the 



pelvic cavity. Such pelves, however, are readily differentiated from the 
tine osteomalacic type, since the sacrum and innominate bones present 
characteristic rhachitic deformities. 

this foim of pelvis was first described by Smellie, who depicted it 
in his anatomical plates. More particular attention was directed to it by 
Stein, and especially by Naegele. It is not of frequent occurrence, 
though Fasbender in 1818 was able to collect 40 cases from the litera¬ 
ture, not a few of which occurred in young children. 

Diagnosis of Rhachitic Pelvis.—Important information as to the 
presence of rhachitis may be elicited by inspection of the patient, when 
characteristic deformities may be noted about the head, vertebral col- 

















RHACHITIC PELVIS 


813 


umn, and lower extremities. In not a few cases the presence of thick¬ 
ened epiphyses at the costal margins—the so-called rhachitic rosary- 
may also serve to call attention to the existence of the disease. 

A decidedly pendulous abdomen in primiparous women is always 
suggestive of marked disproportion between the size of the head and 
the pelvis, and should suggest a search for rhachitic changes. 

The age at which the patient first learned to walk is also of consider¬ 
able importance, as it is well known that children suffering from rha- 
chitis are usually backward in this respect. Again, when the disease 
appears after the first year of life, the child usually ceases to walk dur¬ 
ing its acute stages, and has to learn again at a later period. 

Accurate information concerning the pelvis, however, can be obtained 
only by pelvim¬ 
etry. On exter¬ 
nal mensuration 
the distances be¬ 
tween the spines 
and crests of the 
ilium no longer 
show their normal 
relations, but the 
former approach, 
and not infre¬ 
quently e x c e e d, 
the latter in 
length. Normally, 
there is a difference of 2.5 centimeters between the two, and whenever 
this becomes reduced to 1 centimeter or less rhachitis should be sus¬ 
pected. The distance between the trochanters will be normal or not 
according as one has to deal with the flat or the generally contracted 
type. Baudelocque’s diameter is always considerably shortened. At 
the same time Michaelis’ rhomboid loses its regular outlines, and in 
pronounced cases, owing to the sinking downward and forward of the 
sacrum, becomes converted into a triangular area. The pubic arch is 
usually widened, and the transverse diameter of the outlet is either 
relatively or absolutely increased in length. 

Still more definite information may be gained by internal pelvimetry 
and palpation of the pelvic cavity. The diagonal conjugate is always 
shortened. The anterior surface of the sacrum is more readily accessible 
to the examining fingers, and on careful palpation its upper portion 
is found to be flatter than usual, and in many cases it is convex from 
side to side owing to the protrusion of the vertebral bodies; at the same 
time its lower portion is sharply bent forward. In other woids, the 
normal vertical concavity of the anterior surface of the sacrum becomes 
accentuated, while its lateral concavity becomes decreased, or is even con¬ 
verted into a convexity. 

The average measurements in ten rhachitic pelves in white women 
were: Spines, 25.4; crests, 25.7; trochanters, 29.3; Baudelocque, 17; 
and diagonal conjugate, 10.1 centimeters; while in 79 colored women 







814 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 




the measurements averaged: Spines, 23.7; crests, 24.4; trochanters, 
28.6; Baudelocque, 17.3; and diagonal conjugate, 10.6 centimeters. 

The difference in the measurements between the spines and crests 
in the two races is due to the lesser Haring of the iliac bones and to the 
generally smaller size of the pelvis in colored women. Thus, in two 
series of 707 and 470 normal pelves respectively, the spines and crests 
measured 25.5 and 28 centimeters in white, as compared with 24 and 
26 centimeters in colored women. 

The flat rhachitic pelvis is diagnosticated when the transverse ex¬ 
ternal measurements show but slight diminution, whereas in the gen- 
erallv contracted variety they measure considerably less than normal. 
In practice, the generally and equally contracted variety is usually 
confounded with the generally contracted rhachitic type, and a correct 
diagnosis is not made unless the dried pelvis becomes available; while 
the characteristic deformity of the pseudo-osteomalacic form will lie 
recognized on internal examination, and the decision as to whether it 






Fig. 572. 


-Diagrams Showing Changes in Shape in Rhachitic and Osteomalacic 

Pelves (Schroeder). 


is due to rhaehitis or osteomalacia will be determined by the history of 
the patient, as well as by the detection of definite rhachitic deformities. 

Mode of Production of the Rhachitic Deformities.—In Chapter I, we 
considered the part played by various mechanical factors in the trans¬ 
formation of the foetal into the adult pelvis. Prior to the work of 
Breus and Kolisko, it was generally believed that abnormalities and 
variations in their mode of action upon the softened pelvis also served 
to explain the production of most of the characteristic rhachitic deformi¬ 
ties. This doctrine was developed in great part by Litzmann and 
Schroeder, and obtained almost general acceptance. According to their 
theory, as the young child in the acute stages of rhaehitis is unable 
to walk, and spends its time in a sitting or reclining position, the upward 
and inward force exerted by the femora is in abeyance. Consequently, 
the body weight and the cohesive force at the symphysis pubis are the 
only lorces which come into play, and when the former is transmitted 
by the vertebral column to the sacrum it is resolved into two forces— 
one directed downward and the other forward. As a result, the sacrum 
rotates about its transverse axis, tire promontory being pressed forward 







RHACIIITIC PELVIS 


815 


and downward, while the remainder of the bone moves in the opposite 
direction and tends to assume a more or less horizontal position. The 
extreme upward dislocation of its lower end is resisted by the traction 
exerted upon it and the coccyx by the strong sacrosciatic ligaments, and 
consequently the softened bone becomes sharply flexed at its lower por¬ 
tion, whereby its vertical concavity is accentuated. At the same time, 
owing to the softened condition of the sacrum and the imperfect union 
between the bodies and alae of its vertebrae, the former are pushed out 
beyond the latter, thus converting its normal lateral concavity into a 
convexity. 

As the promontory is displaced forward and downward under the 
influence of the body weight, the posterior surface of the sacrum recedes 
from the superior posterior spines of the ilium, thus subjecting the 
strong iliosacral ligaments to marked tension. As a result, the posterior 
spines are drawn nearer to the middle line, while at the same time the 
anterior portions of the iliac bones flare out, thus accounting for the 
changed position of the anterior superior spines. This movement is 
resisted by the cohesive force exerted at the symphysis pubis, and as a 
consequence the softened bones bend just in front of the sacro-iliac 
synchondrosis, so that the iliopectineal line on either side, instead of 
following a gentle curve, becomes sharply bent at that point. 

Coincident with these changes, the positions of the acetabula become 
altered, and eventually become situated upon the anterior, instead of 
upon the lateral, walls of the pelvis. As a result, when the child begins 
to walk the forces exerted by the femora also add to the flattening of 
the superior strait. On the other hand, owing to the previous non-use 
of the lower extremities, these last forces have not been called into play 
early enough to counteract the widening of the pelvic outlet as a result 
of prolonged sitting, and consequently the ischial tuberosities remain 
flared out. 

The same factors are concerned in the production of the generally 
contracted rhachitic pelvis, its small size being due either to atrophy 
incident to rhachitis, or to the effect of the disease upon a pelvis already 
abnormally small. 

The pseudo-osteomalacic form results when the rhachitic softening 
of the bones is very marked and the child persists in walking. In such 
circumstances not only do the characteristic changes in the sacrum and 
iliac crests develop, but at the same time the anterior wall of the pelvis 
is compressed and its lateral portions are pushed in toward the sacrum, 
the pelvic cavity becoming almost obliterated. 

The mechanical doctrine just outlined was early opposed by Fehling, 
Freund, Ivehrer, and others. The former held that the characteristic 
form of the pelvis might result in utero, from the so-called foetal rhachi¬ 
tis, before the various mechanical factors can come into play. Such a 
view, however, is no longer tenable; for, following the researches of 
Porak, and Kaufmann, it is generally accepted that this disease has 
nothing in common with true rhachitis, but is a distinct entity, which 
has been variously designated as achondroplasia, or chondrodystrophia 

foetalis. 





Freund lias attempted to show that in view of the peculiar nature 
of the sacro-iliac joints the sacrum cannot rotate about its transverse 
axis. His argument, however, appears to have been based in great part 
upon conditions observed in adult life, and he seems to have lost sight 
of the fact that the articular surfaces in early life are almost entirely 
cartilaginous, and thus readily permit of motion in any direction. 

Kehrer believed that the action of certain groups of muscles plays a 
most important part in the production of abnormal pelves. No doubt 
this is true to a certain extent, but it is hardly probable that it is the 
only factor concerned. 

On the other hand, Breus and Kolisko claim that the mechanical 
views of Litzmann and Schroeder are in great part erroneous, as they 
hold that most rhachitic deformities can be explained without invoking 
the intervention of the various physical forces. They have shown that 
rhachitis not only gives rise to a general softening of the pelvic bones, 
but manifests itself more particularly in the imperfect development of 
the ilium and sacrum. Consequently, they contend that the flattening 


of the superior strait is in great part due to the imperfect growth of the 
iliac portion of the innominate bone, while the pubic and sacral portions 
are but little affected. Such an abnormality must inevitably lead to 
the shortening of the anteroposterior diameter, while, as the result of 
the normal development of the pubic portion, the transverse diameter 
will become relatively lengthened. 

Moreover, they hold that the displacement of the sacrum is not due 
to rotation about its transverse axis, but rather to the fact that the 
lack of development at the sacral end of the iliac portion of the innomi¬ 
nate bone interferes with the normal backward displacement of the 
sacro-iliac joint. At the same time they are willing to admit that the 
changes in the curvatures of the sacrum may be due to the action of 
purely mechanical factors. 

At hile the investigations of Breus and Kolisko have thrown great 
light upon the mode of production of rhachitic deformities of the pelvis, 
1 do not believe that they should be accepted as the only explanation. 
Accordingly, it would seem that three factors are concerned in the genesis 
of these deformities: (1) abnormalities in the development of the rha¬ 
chitic bones; (2) the mechanical action of the various forces upon the 
softened bones; and (3) the traction or compression exerted by various 
muscles and ligaments. 


OSTEOMALACIC PELVES 

Inasmuch as osteomalacia gives rise to the most marked pelvic de¬ 
formities with which we are familiar, it was only natural that the atten¬ 
tion of obstetricians should have been directed to it at an early date. 
Cooper performed cesarean section for this condition in 1768, but for 
the main pioneer work w^e are indebted to Stein, Kilian, and Litzmann. 

Nature and Clinical History of Osteomalacia.—Osteomalacia, halis- 
teresis, mollities ossium, or malacosteon disease is a general constitu¬ 
tional disorder, probably dependent upon some as yet unknown perver- 






OSTEOMALACIC PELVES 


817 


sion of the internal secretory organs, which manifests itself by neuritic 
changes, muscular atrophies, and particularly by characteristic changes 
in the bones, which become soft, yielding, and occasionally brittle, and 
consequently undergo marked changes in shape as the result of the action 
of the various mechanical forces to which they are subjected. 

The disease is one of adult life, and is very rarely met with in 
children. It occurs far more frequently in women than in men, espe* 
dally during pregnancy or the puerperium. Litzmann, in 1861, col¬ 
lected 131 cases from the literature, 85 of which were in pregnant or 
puerperal women, 35 in non-pregnant women, and 11 in men. Since 
that time the number of cases in women has markedly increased, whereas 
in 1900 Hahn was able to add only 31 additional instances in males. 

The disease may occur in any part of the world, but is especially fre¬ 
quent, and may even be said to be endemic, in certain localities, notably 
in the Rhine Valley, the Ergolz AVilley in Switzerland, the Olona Valley 
and Calabria in Italy, and in the city of Vienna. It is very rarely 
observed in this country, England, or France, Dock having been able 
to collect only 10 cases in America up to 1896. Tarnier, in his large 
experience, encountered only 3 cases in Paris, and I have seen the same 
number in Baltimore. 

Unless we are prepared to accept the bacterial origin of the disease, 
as urged by Arcangeli and other Italian investigators, no satisfactory 
explanation for its endemic occurrence has been adduced, but it seems 
to be intimately connected with unsanitary surroundings and inferior 
food. This was strikingly illustrated by the experience of Winckel, 
Sr., in Gummersbach in Germany, and of Hoebecke in Sottegem in 
Holland. The former performed 13, and the latter 14 cesarean sections 
upon osteomalacic patients prior to 1840. Since that time improvement 
in the hygienic conditions of both villages, together with more healthy 
occupation for their inhabitants, has led to an almost total disappearance 
of the disease. On the other hand, it may suddenly become endemic in 
localities in which it was previously unknown, as was illustrated by 
Ogata’s experience in the province of Toyama in Japan. Likewise, a 
striking increase in its incidence was noted in Vienna apparently as the 
result of the privations incidental to the World War, and Schlesinger 
states that it especially affected elderly men. 

Osteomalacia may affect any portion of the skeleton, but seems to 
select more particularly the pelvis, vertebrae, and ribs. The fresh bones 
are yellowish or yellowish-brown in appearance, and very soft and brittle. 
In advanced cases their consistence is that of leather or wax, so that 
they can readily be cut with a knife. In the later stages of the disease 
the spongy bones present a markedly areolated appearance on section, 
and in some instances are so rarefied that only the outer layers remain 
intact. At the same time they become much lighter, the specific gravity 
being frequently reduced by one half. 

Under the microscope the marrow spaces are found to be greatly 
enlarged, and there is a marked increase in vascularity. The most im¬ 
portant change, however, consists in the substitution of osteoid tissue 
in place of the true bone surrounding the haversian canals. 


818 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 


All of the earlier writers upon the subject considered that the changes 
in the bone resulted from decalcification, which was due to the presence 
of lactic or a related acid in the circulating blood. But, after the 
correctness of this view had been denied by Virchow in 1852, the writers 
upon the subject became divided into two camps: the one claiming 
that the essential feature of the disease is decalcification, and the other, 
a disturbance in the relation between resorption and apposition, by which 
osteoid instead of osseous tissue is formed. Formerly, it was thought that 
the bone lesions in rhachitis and osteomalacia could be readily differenti¬ 
ated, but Recklinghausen, who was formerly a pronounced dualist, stated 
in his monumental work that it was practically out of the question. Full 
details of this discussion are to be found in the writings of Gelpke, 
Winckel, Laufer, Dibbelt, Marquis, and Christofoletti. 

One of the most important contributions to the subject was made by 
Fehling in 1888, who advanced the theory that the disease was a tropho¬ 
neurosis of ovarian origin. Fie believed that characteristic changes 
could be made out in the ovaries, that these gave rise to reflex stimula¬ 
tion of the vasodilators supplying the bones, and that cure could be 
effected by removal of the ovaries. Although the various investigators, 
who have studied those organs histologically have been unable to demon¬ 
strate the existence of characteristic lesions, it seems highly probable 
that the disease is in some way associated with ovarian hyperfunction; 
otherwise it would be very difficult to comprehend the results which have 
followed castration, as Seitz reports that 87 per cent, of 328 patients 
were definitely cured by the operation. Benzel in 1919 analyzed the 
results obtained in the Strassburg clinic, and stated that while cure 
occasionally followed the administration of adrenalin or the use of X-rays 
the most brilliant results were obtained by castration. 

It is not yet known whether the disease results from a primary dis¬ 
turbance of the internal secretion of the ovaries, or whether the latter is 
a manifestation of hypof unction on the part of the adrenals. A cer¬ 
tain amount of evidence in favor of the latter view is afforded by the 
favorable results obtained by the administration of adrenalin, as recom¬ 
mended by Bossi. It appears that osteomalacic women can take with 
impunity quantities of the drug, which would give rise to serious symp¬ 
toms under other conditions, and that its prolonged administration is 
followed by cure in about one quarter of the cases. Furthermore, Varaldo 
states that its use is followed by the appearance of definitely degenerative 
changes in the ovaries. 

More important, from a practical standpoint, is the clinical history 
of the affection. In its earliest stages it is characterized by peculiar 
muscular palsies, which more especially affect the iliopsoas, and which 
are often accompanied by contractures of the abductor muscles of the 
thigh and by increased patellar reflexes. A little later rheumatoid pains 
make their appearance in various portions of the body, and at the same 
time the pel\is, ribs, and vertebral column become very sensitive upon 
pressuie. As the disease advances still further and the bones become 
softei, \aiious deformities appear, which are particularly marked in the 
vertebral column and pelvis. 









OSTEOMALACIC PELVES 


819 


The lllstor y of osteomalacic patients is usually quite characteristic: 
lhe multiparous woman complains of muscular symptoms and rheuma¬ 
toid pains during pregnancy. The same symptoms recur with added 
intensity m the succeeding pregnancy, and labor becomes more difficult, 
bhould pregnancy again occur, the rheumatoid pains become severe and 
locomotion is so interfered with that for the last months the patient is 
obliged to take to her bed, and craniotomy or cesarean section is usually 
necessary at the time of labor. Shortly after delivery the pains disap- 
peal, and when the patient is able to get about again she notices that 



Fig. 573. 



Fig. 574. 


Fig. 575 

Figs. 573-575.— Osteomalacic Pelvis. 



she has become some inches shorter than previously, the diminution in 
stature being sometimes associated with kyphotic changes in the vertebral 
column. 

To sum up, a history of rheumatoid pains and difficult locomotion 
requiring rest in bed during pregnancy, associated with a decrease in 
height, is almost pathognomonic of osteomalacia. 

Changes in the Shape of the Pelvis.—The extent of the deformity 
resulting from osteomalacia depends entirely upon the degree of soften¬ 
ing which the various pelvic bones have undergone. According to Kehrer, 
in the early stages of the disease the pelvis is simply flattened as the 







S20 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 


result of the forcing downward and forward of the promontory of the 
sacrum. 

In the later stages of the disease, when the bones have become very 
soft, the pelvis takes on a characteristic compressed appearance. The 
body weight presses the promontory still further downward and for¬ 
ward, while the upward and inward forces exerted by the femora push 
the lateral walls of the pelvis inward, so that the superior strait assumes 
a trefoil appearance, and in extreme cases becomes almost entirely oblit¬ 
erated. At the same time the ischiopubic rami are approximated, and 
the pubic arch is converted into a narrow slit into which it is some¬ 
times impossible to insinuate the fingers. The pubic rami are pushed 
markedly forward, giving rise to a beaklike protuberance upon the ante¬ 
rior wall of the pelvis. Coincident with these changes, there is a marked 
diminution in the size of the pelvic cavity and of the inferior strait, 
though in not a few cases, owing to constant sitting upon the softened 
bones, the tubera ischii are relatively flared out. In advanced cases the 



pelvis is very much deformed, and may present any one of an almost 
infinite variety of bizarre shapes. 

Diagnosis.—The diagnosis is readily made, as careful inquiry will 
usually elicit the characteristic clinical history of the disease; while 
examination of the pelvis will show that it is markedly compressed in 
all directions, and the pathognomonic changes in the pubic arch can 
hardly escape detection. Indeed, the only form of pelvis with which it 
might be confounded is the very rare transversely contracted Bobert 
pelvis, but the clinical history and the lack of anteroposterior shortening 
in the latter will usually enable one to differentiate between them. 

LITERATURE 

Ahlfeld. Die Diagnose ties einfach platten Beckens an tier Lebentlen. Zeitschr. 
f. Geb. u. Gyn., 1895, xxxii, 356-367. 

Arcangeli. Aetiologie n. Pathogenese tier Osteomalacie. Ref. Zentralbl. f Gvn 
1910, 430-431. 









LITERATURE 


821 


Benzel. Die Behandlung dor Osteomalacie an der Strassburger Frauenklinik. 
Archiv f. Gyn., 1917, cvii, 268-282. 

Betschler. Annalen der klin. Anstalten. Breslau, 1832, i, 24-60, ii, 31. 

Bossi. Nebenuieren und Osteomalakie. Zentralbt. f. Gyn., 1907, 172-173. 

Breus und Kolisko. Rachitis-becken. Die pathologischen Beckenformen. Leip¬ 
zig u. Wien, 1904, i, Theil 2, 435-636. 

Ciiristofoletti. Zur Pathogenese der Osteomalazie. Gyn. Rundschau, 1911, v, 
113-144. 

Deventer. Neues Hebammenlicht, III. Aufl., Jena, 1728, 199. 

Dibbelt. Weitere Beitrage zur Pathologie der Rhachitis. Yerh. der deutschen 
pathologischen Gesellschaft, 1910, xiv, 294-299. 

Dock. Osteomalacia, with a New Case. Amer. Jour. Med. Sciences, 1895, cix, 
499-516. 

Fasbender. Ueber das pseudo- und das rachitisch-osteomalacische Beckon. Zeit- 
schr. f. Geb. u. Gyn., 1878, ii, 332-345. 

Fehling. Die Entstehung der rachitischen Beckenform. Archiv f. Gyn., 1877, xi, 
173-183. 

Ueber Kastration bei Osteomalacie. Yerh. d. deutschen Gesellsch. f. Gyn., 1888, 
ii, 311-318. 

Freund. Ueber das sogenannte kyphotische Becken. Gyn. Klinik, 1885, 1-134. 

Gelpke. Die Osteomalacie im Ergolztliale. Basel, 1891. 

Hahn. Ueber Osteomalacie beim Manne. Zusammenfassendes Referat. Zentralbl. 
f. die Grenzgcbiete der Med. u. Chir., 1900, iii. 

Kassowitz. Die normale Ossification und die Erkrankungen bei Rhachitis und 
hereditarer Syphilis. Wien, 1882. 

Kaufmann. Untersuchungen iiber die sogenannte fotale Rhachitis. Berlin, 1892. 

Kehrer. Zur Entwickelungsgeschicte des rhachitischen Beckons. Archiv f. Gyn., 
1873, i, 55-99. 

Kilian. Beitrage zur einer genauen Kenntniss der allgemeinen Knochenerweichung 
der Frauen. Bonn, 1829. 

Das halisteretische Becken. Bonn, 1857. 

Latzo. Beitrage zur Diagnose und Therapie der Osteomalacie. Monatsschr. f. 
Geb. u. Gyn., 1897, vi, 571-608. 

Laufer. Zur Path. u. Therapie der Osteomalacie des Weibes. Zentralbl. f. die 
Grenzgebiete der Med. u. Chir., 1900, iii, Nr. 1. 

Litzmann. Die Formen des Beckens, nebst einem Anhange iiber Osteomalacie. 
Berlin, 1861. 

Die Geburt bei engem Becken. Leipzig, 1884, 36. 

Marquis. Diagnostic et role de la decalcification gravidique. L ’obstetrique, 1910, 
v, 561-580. 

Michaelis. Das enge Becken. Leipzig, 1851. 

Muller. Zur Frequenz und Aetiologie des allgemein verengten Beckens. Archiv 
f. Gyn., 1880, xvi, 155-174. 

Naegele. Das schrag verengte Becken. Mainz, 1839. 

Ogata. Ueber das Wesen der Rhachitis und Osteomalacie. Beitrage zur Geb. u. 
Gyn., 1911, xvii, 23-80. 

Porak. De l’achondroplasie. Nouvelles archives d’obst. et de gyn., December, 
1889. 

Recklinghausen. Rhachitis und Osteomalacie. Jena, 1910. 

Schlesinger. Zur Kenntniss der gehauften osteomalakie-ahnliclien Zustande in 
Wien. Wiener klin. Wochenschr., 1919, Nr. 10. 

Schliephake. Ueber path. Beckenformen beim Fotus. Archiv f. Gvn., 1882, xx, 
435-454. 




822 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 


Schmorl. Die path. Anatomic der rachitisclien Knochenerkrankung. Ergebnisse 
der inneren Medizin, 1909, iv. 

Seitz. Die Osteomalacie in ihren Beziehungen zur inneren Sekretion und zur 
Schwangerschaft. innere Sekretion u. Schwangerschaft. Leipzig, 1913. 

Smellie. Anatomical Tables, etc. New edition, Edinburgh, 1787. 

Spillmann. Le Rachitisme. These de Nancy, 1900. 

Stein. Kleine Werke zur prakt. Geburtshiilfe, 1798, 283-340. 

Die Lehranstalt der Geburtshiilfe zu Bonn, Elberfeld, 1823, I. Heft. 

Tarnier et Budin. Traite de l’art des accouchements, 1898, iii. 

Varaldo. Exp. Untersuchungen iiber Eierstocksveranderungen infolge wieder- 
holten Adrenalineinspritzungen. Zentralbl. f. Gyn., 1913, 1350-1353. 

Virchow. Archiv f. path. Anat. u. Physiol., 1852, iv. 

"VVinckel. Behandlung der Osteomalacie. Pentzoldt u. Stintzing. Handbuch der 
spec. Therapie, 1896, Bd. v, Abth. vii, 214-242. 

Zwei,fel. Aetiologie, Prophylaxis und Therapie der Rachitis. Leipzig, 1900. 




CHAPTER XXXV 


ABNORMAL PELVES RESULTING FROM PRIMARY ANOMALIES IN 

DEVELOPMENT 


Three separate groups of cases are differentiated according as the 
abnormalities are: (a) Generalized and symmetrical; (b) localized and 
asymmetrical; (c) localized and symmetrical. 


I. GENERALIZED AND SYMMETRICAL ANOMALIES IN 

DEVELOPMENT 

Abnormal development may manifest itself in an excess or in a lack 
of the general growth of the pelvis. In the former case we have to do 
with the generally enlarged or justomajor pelvis, and in the latter with 
one of several varieties—the generally contracted (justominor) pelvis, the 
infantile, the masculine, or the dwarf type. 

The Generally Enlarged (Justomajor) Pelvis.—This variety of pelvis 
is symmetrically enlarged in all its parts, and differs from the normal 
only by its increased size. It is usually observed in giantesses, and occa¬ 
sionally in women of normal stature; indeed, if the external measure¬ 
ments alone are taken as a criterion, it is of quite frequent occurrence 
in the latter. 

According to Schauta, the various diameters in this type rarely exceed 
the normal by more than 2 centimeters, though he refers to De la Tou- 
rette’s case, in which the anteroposterior and transverse diameters of the 
superior and inferior straits measured 14.9 and 17, and 14.9 and 14.9 
centimeters, respectively. In not a few cases the greatest increase is in 
the anteroposterior diameter, while the others remain practically normal. 
Occasionally the enlargement may be limited to the superior strait, while 
the lower portions of the pelvic canal retain their usual proportions, 
thus producing a funnel-shaped pelvis. In rare instances excessive 
external transverse measurements may be due io the fact that the fossa 
join the main body of the iliac bones at a less obtuse angle than usual. 

This variety of pelvis has no effect upon the course of labor, except 
that its excessive size now and again obviates the necsesity foi the usual 
mechanism, and consequently the head may be born so lapidly and 
suddenly that extensive perineal tears result. 

The Generally Contracted (Justominor) Pelvis.—This type was first 
described by Deventer as the pelvis nimis parva, while Stein later applied 
to it the designation justominor. All of its measurements are more or 
less proportionately shortened, so that at first glance the pelvis may 

823 


824 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


appear perfectly normal, the narrowing being discovered only after men¬ 
suration. 

As a rule, the generally contracted pelvis is lighter in texture, and its 
component parts are more delicately formed than usual. The sacrum is 
smaller, and the alae proportionately shorter than the bodies of its verte¬ 
brae. At the same time its vertical concavity is sometimes increased. 
On careful examination it is found that the decrease in size is not uni- 



Fig. 577. 




Contracted Pelvis. 


* 


form, as occasionally the conjugata vera is relatively shorter than the 
transverse diameter of the superior strait, while in every fifth or sixth 
specimen the inferior is relatively smaller than the superior strait, so 
ihat we have a type approaching the simple flat or funnel-shaped pelvis, 
1 cspectively. Michaelis considered that the anteroposterior shortening 
in this class of pelves rarely exceeds 1.5 centimeters; and, although this 
appears to Be too conservative a figure, it may be said that whenever the 
conjugata vera measures 8 centimeters rhachitic changes should be sus¬ 
pected. 










GENERALIZED AND SYMMETRICAL ANOMALIES 


825 


This pelvis is usually met with in small women, although one is 
occasionally surprised to find it in those of large stature. It is generally 
said to occur but rarely in Germany and France, although it was ob¬ 
served in 37 and 28 per cent, of the contracted pelves studied by Muller 
and Conner respectively; and Richelet states that it is much more com¬ 
mon in France than is generally believed. My own observations show 
that it is by no means unusual in Baltimore, as it was noted in 5.3 per 
cent, of our white, and in 22.9 per cent, of our black patients. Further¬ 
more, in white women it ranks just below the typical funnel pelvis in 
order of frequency; while in black women it represents the most usual 
type of contracted pelvis, comprising 33.4 and 53.7 per cent, of all pelvic 
abnormalities in the two races respectively. It is undoubtedly a sign 
of degeneration, and in the colored race is a manifestation of the im¬ 
perfect physical development incident to living in large cities. Muller 
considered that its frequency in Berne was probably due to the prevalence 
of cretinism in that locality, but the fact that Gonner observed it 
almost as frequently in Basel, where the latter disease occurs but rarely, 
militates against such a view. It is quite possible that not a few so- 
called justominor pelves are really of rhachitic origin, especially in 
negroes, and that in such cases the other more characteristic changes 
are lacking. 

The diagnosis is readily made. The existence of a generally con¬ 
tracted pelvis should always he suspected in small women, and espe¬ 
cially in poorly developed working women, although it should not be 
forgotten that it may occur in large and apparently well-formed indi¬ 
viduals. Accurate information can be obtained by means of pelvimetry. 
All of the external measurements are considerably and uniformly short¬ 
ened. Internal examination shows a shortened conjugata vera, with 
general smallness of the pelvic cavity, typical rhachitic changes being 
absent. The average measurements in 36 white women in my clinic 
presenting pelves of this character were: Spines, 23.25; crests, 25.7; 
trochanters, 26.3; Baudelocque, 17.9 ; and diagonal conjugate, 11.1 centi¬ 
meters, while in 167 colored women each measurement was a few milli¬ 
meters shorter. 

It is usually taught that a generally contracted pelvis with a con- 
jugata vera of a given length offers a greater obstacle to laboi than a 
flat pelvis offering a similar measurement, and for practical purposes 
half a centimeter is usually added to the latter to reduce it to terms of 

the former. 

The Masculine Pelvis.—Michael is directed attention to the fact that 
generally contracted pelves are occasionally encountered in which the 
bones are thicker and clumsier than usual and approach the male type. 
Pelves of this class occur much less frequently than is generally believed, 
as many which are so described are in reality typical funnel pelves. 
They have the same effect upon labor as the ordinary justominor variety, 
though in many instances the relatively great contraction of the inferior 

strait may add to the dystocia. . 

Berrv Hart pointed out in 1916 that the pelvis may occasionally pre¬ 
sent an “inversion” of male and female characteristics, so that either 


826 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 



its iliosacral or iscliiopubic portion may conform to the ^male type, 
while the rest retains its typical feminine conformation. I he former 
leads to abnormalities of the superior strait, while in the latter the 
iscliiopubic rami become so approximated that a funnel pelvis results. 

The Infantile Pelvis.—In rare instances, as the result of disease, 
which has caused the individual to spend her entire life in bed without 
attempting to sit up or walk, the pelvis retains the characteristic in¬ 
fantile form to which reference 
was made in Chapter I. Ex¬ 
amples of this abnormality 
have been described by Naegele, 
Leisinger, Bittner, and Gurlt, 
but naturally it possesses no 
obstetrical significance. 

The Dwarf Pelvis.—Ac¬ 
cording to Breus and Kolisko, 


Fig. 580.— Chondrodystrophia Fcetalis. several varieties of dwarfs must 

be distinguished — i. e., the 
chondrodystrophic, the “true,” the cretin, the rhachitic, and the hypo¬ 
plastic dwarf. 

In the first-mentioned variety the deformity results from chondro¬ 
dystrophia foetalis (Kaufmann), achondroplasia (Parrot and Porak), or 
foetal rhachitis, as the disease has been variously designated. The affec¬ 
tion is not allied to rhachitis, but is an entirely independent disease which 
begins in utero, and whose etiology is as yet unknown; although many 
recent writers are inclined to attribute it to abnormalities in the func¬ 
tion of the endocrine glands, Wagner believing that it is associated 
with hyperfunction of the ovaries. It is characterized by changes in 
the epiphyseal cartilages, which interfere with the normal apposition of 
bone, with the result that the shafts of the long bones are imperfectly 
developed so that the individual presents a normally formed body, while 
the extremities are short and stumpy. In many instances the head is 
brachycephalic, with a prominent forehead and saddle nose. The mus¬ 
culature is often excessively developed, so that chondrodystrophic dwarfs 
may be unusually strong. Full details concerning the condition may be 
found in Rischbieth and Barrington’s monograph on dwarfism. It is 
sometimes hereditary, and in such cases the tendency is usually trans¬ 
mitted through the father. Persons presenting the abnormality are fre¬ 
quently exceptionally fertile, and thus contrast markedly with cretin 
dwarfs, in whom sterility is the rule. 

In the “true” dwarf there is a proportionate lack of general develop¬ 
ment, which is particularly characterized by the fact that the various 
epiphyses do not undergo ossification, but remain cartilaginous, until an 
advanced age. 

In the cretin dwarf the lack of development is general. The bony 
changes are allied to those observed in the true dwarf, but are less 
marked. 


The term rhachitic dwarf should not be applied to individuals whose 
short stature is due to skeletal deformities, but should be restricted to 




GENERALIZED AND SYMMETRICAL ANOMALIES 


827 


those who would fall far below the normal height even if one imagined 
the deformities straightened out. 

In the hypoplastic dwarf the changes are quantitative instead of 
qualitative, so that the individual differs from the normal only in her 
miniature appearance. 

Each of these varieties of dwarfs has a characteristically shaped 
pelvis, which is more or less generally contracted. 

The Chondrodystrophic Dwarf Pelvis .— 

Fig. 58'0 represents a chondrodystrophic in¬ 
fant, and Fig. 581 a chondrodystrophic 
dwarf, whose pelvis, described by Breus and 
Kolisko, is reproduced in Fig. 582. The 
woman was twenty-seven years old and 123 
centimeters tall, and died after a cesarean 
section. 

This variety of pelvis is characterized by 
an extreme anteroposterior flattening, so that 
on first glance one might believe that one 
had to deal with a rhachitic pelvis. On 
closer examination, however, it is seen that 
the flattening is due to the imperfect de¬ 
velopment of the portion of the iliac bone 
entering into the formation of the iliopec- 
tineal line, owing to which the sacral articu¬ 
lation is brought much nearer the pubic bone 
than usual. In 6 pelves of this character 
described bv Breus and Kolisko the con- 

J 

jugata vera varied from 4 to 7 centimeters, 
while the transverse diameter of the superior 
strait was but slightly shortened, varying 
from 11 to 12 centimeters. 

The True Dwarf Pelvis (Pelvis Nana). 

—This variety of pelvis is extremely rare, 
only 4 well-marked specimens being in 
existence—those described by Naegele and 
Boeckh, Schauta, Paltauf, and Breus and 
Kolisko, two of which were in females. 

The pelvis is generally contracted and tends 

toward the infantile type, but its most characteristic feature is the per¬ 
sistence of cartilage at all the epiphyses. Thus, in BoecldTs pelvis, 
which belonged to a thirty-one-vear-old woman, 108 centimeters tall, 
the Y T -shaped cartilage at the acetabulum was clearly marked and the 
sacral vertebrae were not fused together (Fig. 584). 

The Cretin Dwarf Pelvis. —This is a generally contracted pelvis with 
poorly developed and imperfectly formed bones. Unlike that of the true 
dwarf, it does not present infantile characteristics, but shows signs of a 
steady though imperfect growth throughout early life. Unossified carti¬ 
lage may be present here and there in young subjects, but it disappears 



Fig. 581. — Chondrodystro¬ 
phic Dwarf (Breus and 
Kolisko). 










828 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 

with advancing age and is never found in all the epiphyses as in th( 1 
true dwarf pelvis. 


Fig. 582. Fig. 583. 

Figs. 582, 583.— Chondrodystrophic Pelvis (Breus and Kolisko). 


The Rhachitic Dwarf Pelvis .—True rhachitic dwarfs are rare, and ij 
possess generally contracted, rhachitic pelves, which do not differ from ' 


those described in the previous chapter except by their small size. 


The Hypoplastic Dwarf Pelvis .—According to Breus and Kolisko this 
variety of pelvis is observed in very small individuals, and is simply a 


Fig. 584. 


Fig. 58J 


Figs. 584, 585.— True Dwarf Pelvis (Boeckh). 





















LOCALIZED AND ASYMMETRICAL ANOMALIES 829 

normal pelvis in miniature. It differs materially from that of the true 
dwarf in that it is completely ossified. 


II. LOCALIZED AND ASYMMETRICAL ANOMALIES IN 

DEVELOPMENT 

The Obliquely Contracted or Naegele Pelvis.—Naegele, in 1803, was 
the first to recognize the significance of this variety of pelvis, and in 1839 
published a monograph upon the subject based upon the study of 35 
specimens, one of which had been obtained from an Egyptian mummy. 

The Naegele pelvis presents the following characteristics: The sacral 
ala on one side is normal, while the other is either lacking or imper¬ 
fectly developed, and the corresponding sacral foramina are smaller. In 
the great majority of cases the sacrum and the innominate hone are 
firmly synostosed on the affected side. At the same time the latter is 
pushed upward and backward, as well as inward from the region of the 
acetabulum, so that its crest is at a higher level than that of its fellow. 
The iliopectineal line is less curved than normally, being almost straight 
when the deformity is marked, while upon the opposite side the curvature 
is accentuated, particularly in the anterior portion. Corresponding 
with the change in position of the innominate bone on the affected side, 
the ischial tuberosity and spine are displaced inward, upward, and back¬ 
ward, thereby approaching the outer margin of the sacrum and narrowing 
the sacrosciatic notch. The symphysis pubis is displaced toward the well 
side, while the pubic arch instead of looking directly forward is directed 
toward the abnormal side of the sacrum. The sacrum itself is displaced 
toward the ankvlosed side, while its anterior surface is directed more or 
less obliquely toward it. 

As a result of these changes the pelvis becomes obliquely contracted, 
the superior strait being ovate in shape, with its small pole directed 
toward the abnormal sacro-iliac joint and its large end toward the 
horizontal ramus of the pubis on the well. side. Consequently, its oblique 
diameters are of unequal length, the shorter extending from the sacro¬ 
iliac synchondrosis of the well side to the iliopectineal eminence on the 
diseased side, while the conjugata vera is usually somewhat lengthened 
and is directed obliquely. 

The walls of the pelvis converge below, so that the contraction in¬ 
volves the entire pelvic cavity, hut is relatively greater in the plane of 
least pelvic dimensions and in the inferior strait than at the superior 
strait. The acetabulum on the diseased side is directed more anteriorly, 
while that on the well side looks almost directly outward. 

The distances from the promontory of the sacrum to the acetabulum 
and from the tip of the sacrum to the ischial spine are markedly dimin¬ 
ished on the diseased side. At the same time the distance between the 
tuber ischii of the diseased side and the opposite posterior superior spine 
is less than that between the tuber ischii of the well and the correspond¬ 
ing spine of the diseased side. Moreover, the tip of the spinous process of 
the last lumbar vertebra is nearer the anterior superior spine of the 







830 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


ilium on the diseased than on the well side, while the distance from 
the lower margin of the symphysis to the posterior superior spine is less 
upon the well side. 

Mode of Production .—The genesis of this variety of pelvic deformity 
has given rise to a great deal of discussion, some writers claiming that 
the defect in the sacrum is primary and the synostosis secondary; others, 
that the synostosis results primarily from changes which bring about 
more or less destruction of the sacral ala. The former view was advo¬ 
cated particularly by Erma, Hohl, Litzmann, Olshausen, and Schauta, 
and the latter by Betschler, E. Martin, Thomas, and others. 

It is now generally admitted that the first-mentioned view is correct, 
Hohl and others having shown that the entire sacral ala might be lacking 



without a sign of synostosis. Moreover, Thomas and Kundrat, among 
other observers, have demonstrated that the ala of one or more sacral 
vertebrae may be absent or imperfectly developed while the others are 
normal. Accordingly, while synostosis usually occurs at the affected 
sacro-iliac synchondrosis, it is not a necessary characteristic of this 
variety of pelvis. 

I he mechanism by which the deformity is produced is as follows: 
Owing to the asymmetry of the sacrum there is compensatory scoliosis 
of the lumbar portion of the vertebral column with its convexity on the 
diseased side. This causes the pelvis to assume an angle with the 
horizon, thereby bringing about a lowering of the acetabulum on the 
diseased side. As a consequence greater pressure is exerted by the femur 
on that side, which gradually brings about an upward, backward, and 
inward displacement of the corresponding innominate bone. Owing to 
the increased pressure, the synovial membrane at the sacro-iliac synchon- 






LOCALIZED AND ASYMMETRICAL ANOMALIES 


831 


drosis gradually undergoes pressure necrosis, and synostosis eventually 
results. 

Frequency. —Thomas, in 1861, was able to collect from the litera¬ 
ture a description of 50 pelves of this character. Since then additional 
cases have been described, but at present the entire number does not 
exceed 100. 

Diagnosis .—Generally speaking, the condition is readily recognizable, 
provided that one’s attention is directed to its possible existence. Un¬ 
fortunately, since the customary external measurements give no clew to 
its presence, the diagnosis is usually not made until labor is far ad¬ 
vanced, when the evident dystocia forces one to look for the cause. 
The patients do not limp, and as a rule give no history suggestive of 



Fig. 588. —Posterior View of Obliquely Contracted Pelvis (Naegele). 

trouble at the sacro-iliac joint. On the other hand, the existence of sco¬ 
liosis, a variation in the height of the hips, or a difference in the distance 
between the spine of the last lumbar vertebra and the posterior superior 
spine on either side should cause one to suspect its possibility, when a 

radiogram will settle the question. 

Naegele suggested five measurements which should be made in such 
cases: (1) From the tuber ischii of one side to the opposite posterior 
superior spine; (2) from the anterior superior spine of one side to the 
opposite posterior superior spine; (3) from the spine of the last lumbar 
vertebra to the anterior superior spine on either side; (4) from the 
trochanter to the opposite posterior superior spine; (5) from the lower 
mar-in of the symphysis pubis to the posterior superior spines on either 
side! Normally, these various measurements should be the same on 
both sides, but they differ considerably in obliquely contracted pelves. 

Owing to the difficulty of definitely locating their end points, the 
first fourth, and fifth measurements are rarely employed; but the in- 


















832 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


formation obtained from the second and third is of very considerable 
value. A difference of more than 1 centimeter between these measure¬ 
ments on the two sides indicates an obliquely contracted pelvis, but is 
not sufficient to enable one to differentiate between the Naegele and the 
other varieties. On internal examination the conjugata vera is not 
shortened, but on measuring the diagonal conjugate it is found that the 
symphysis pubis, instead of being situated directly in front of the 
promontory, lies considerably to one side of it. On palpation it is found 
that the sacrum is asymmetrical, and that the lateral wall of the pelvis, 
as well as the ischial spine and tuberosity, approaches it much more 
closely on the diseased than on the opposite side, while the iliopectineal 
line is markedly flattened. At the same time the distance between the 
tubera ischii is greatly diminished. 

Effect upon Labor .—"When the deformity is at all pronounced, the 
side of the pelvis corresponding to the small end of the oval is so con¬ 
tracted as to be useless for the passage of the child, so that engagement, 
if it is to occur at all, must take place on the opposite side. In effect, 
the pelvic inlet becomes converted into one of the generally contracted 
type, and an idea of its- available space is gained by measuring, not the 
conjugata vera, but the distance between the symphysis pubis and the 
sacro-iliac synchondrosis on the normal side. If engagement is possible, 
the labor will progress more favorably when the occiput is directed 
toward the iliopectineal eminence of the diseased than toward that of 
the well side, tor the reason that in the first instance the biparietal 
diameter lies in the long oblique instead of in the short oblique diameter 
of the superior strait. 

Owing to the progressive increase of the contraction in the lower- 
portion of the pelvis, still further difficulty is experienced when the head 
attempts to pass between the ischial spines and tuberosities, and the 
possibility of delivery depends upon the distance between these points. 

Prognosis. If the deformity is at all pronounced the prognosis is 
bad, unless cesarean section be performed. Litzmann stated that in 
pre-antiseptic days 22 out of 28 mothers died in the first labor, and that 

only 6 labors ended spontaneously out of the 41 making up his entire 
series. 


Generally speaking, spontaneous labor is out of the question unless 
the short oblique diameter measures at least 8.5 centimeters. Below 

!i” S Ce , arean section is the 011 ly rational method of treatment if 
the child is alive and the patient in good condition. Pinard in one case 

gamed sufficient room for the delivery of the child by sawing through the 

onthe' ITT °V P P f iS the asCendi "g ™nus of the ischium 

on the diseased side—ischiopubiotomy. The operation was stromrlv 
tiie re“n thT^ho^ Tl ^ P< l rformanee is not to be recommended, for 

SLizsz srsr at one sacro -° iac joint may 





LOCALIZED AND ASYMMETRICAL ANOMALIES 833 

III. LOCALIZED AND SYMMETRICAL ANOMALIES IN 

DEVELOPMENT 


Fig. 589. Fig. 590. 

Figs. 589-590. —Transversely Contracted Pelvis (Robert). 

The Transversely Contracted or Robert Pelvis.—Imperfect develop¬ 
ment of both sacral alae produces a pelvis which is markedly contracted 

f transversely, and is sometimes described as the double Naegele pelvis. 
This variety is extremely rare, Tarnier stating that only 10 cases had 
been described up to 1898 (Fig. 589). 

In the pelvis described by Robert, both alae of the sacrum were lack¬ 
ing, and the innominate bones were firmly synostosed with the rudi¬ 
mentary sacrum. The anterior surface of the latter was convex in both 
directions. Owing to the imperfect development of the sacrum, the 
pelvis was markedly contracted transversely, and only slightly antero- 
posteriorly, the transverse and anteroposterior diameters of the superior 
and inferior straits measuring 7 and 9.7, and 5.1 and 10.6 centimeters, 
respectively. 

Just as in the Naegele pelvis, bony union between the sacrum and 
innominate hones is not an essential characteristic, and is occasionally 
lacking, sometimes on one, much more rarely on both sides. \A here 
there fs a difference in the development of the alae on the two sides it 
can readily he understood how an asymmetrically transversely contracted 

pelvis may result. 

The diagnosis is readily made, all of the transverse external measure¬ 
ments being markedly shortened while the external conjugate remains 
practically normal. Internal examination shows the conjugata vera to be 



These may be of several characters: (a) Imperfect development of 
Doth sacral alae; ( b ) lack of union at the symphysis pubic; (c) lack of 
development of the vertebral bodies of the sacrum; ( d) assimilation of 
:he last lumbar vertebra with the sacrum, or of the first sacral vertebra 
with the lumbar column. 










834 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 

only slightly changed, while it is hardly possible for the close approacl 
of the ischial spines and tuberosities to one another to escape recogni-1 
tion. In all cases thus far reported the transverse narrowing of the pelvis I 
was so great as absolutely to preclude the possibility of the birth of a | 
living child, and accordingly cesarean section is the only rational method r 
of treatment. 

Split Pelvis.—In rare instances union between the pubic bones at the 
symphysis does not occur, and the anterior portions of the pelvis gape 
widely (Fig. 592). This condition is usually associated with ectopia 
of the bladder and imperfect development of the lower portion of the 



Fig. 591. Fig. 592. 

Figs. 591, 592. — Split Pelvis (Kreus and Kolisko). 


anterior abdominal wall. As such abnormalities greatly diminish the 
probability of prolonged life, the condition is more common in young 
children than in adults. We are indebted to Litzmann for the first 
accurate description of a pelvis of this character from an obstetrical 
point of view. 

In the split pelvis, owing to descent of the promontory of the sacrum 
and the absence of union at the symphysis, there is marked transverse 
widening of the posterior portion of the pelvis, while its anterior portions 
extend more or less parallel. External pelvimetry in such cases shows a 
marked flaring of the anterior superior spines of the ilium, and were 
the defective condition of the pubis not clearly evident a rhachitic pelvis 
might be suspected. 

I he distance between the extremities of the pubic bones varies con¬ 
siderably, and occasionally is as great as 14 centimeters. This space is 
usually filled by a fibrinous band. Schickele, in 1901, reported a case 

















LOCALIZED AND ASYMMETRICAL ANOMALIES 


835 


)f labor in a pelvis of this character, and stated that 8 others were to be 
ound in the literature. In only 2 of them was labor spontaneous, but 
n none was great difficulty experienced; consequently for practical pur¬ 
poses the pelvis may be considered as generally enlarged, the dystocia 
jeing due to abnormalities of mechanism resulting from the absence of 
i resistant anterior pelvic wall. Gemmel and Paterson in 1913 described 
a remarkable case, in which the entire generative tract, as well as the 
oladder, was doubled. In successive pregnancies conception occurred 
in either uterus and eventuated in spontaneous labor. Breus and Kolisko 
pve an excellent description of several hitherto undescribed cases, and 



Fig. 593. —Contracted Pelvis Due to Absence of Bodies of Sacral Vertebrae 

(Litzmann). 

discuss fully the mechanical factors concerned in their production; while 
Miller has carefully reviewed the literature upon the subject up to 

1918. 

Imperfect Development of the Vertebral Bodies of the Sacrum.— 

Litzmann has described a remarkable pelvis, in which almost the entire 
sacrum was lacking. This defect was associated with considerable trans¬ 
verse contraction, which increased as the inferior strait was approached, 
the transverse diameter of the superior strait measuring 10.5 centimeters, 
while the distance between the ischial spines and ischial tuberosities was 
6.5 and 8.5 centimeters respectively (Fig. 594). 

Assimilation Pelvis. —Quite frequently the transverse processes of 
the last lumbar vertebra may be transformed into structures similar to 
the lateral masses of the sacral vertebrae, and fuse with them. In this 
event the former assumes the functions of the first sacral vertebra, the 
sacrum being now composed of 6 instead of 5 pieces. In other instances 
the first sacral vertebra may take on the characteristics of a lumbar ver¬ 
tebra and become assimilated to the lumbar column, so that there are 6 










830 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


lumbar and only 4 sacral vertebrae. Occasionally the first coccygeal verte 
bra may become assimilated with the sacrum, but this has no effect upo 
the character of the pelvis. 

Unless the entire vertebral column is available for study, it is fre 
quently difficult to determine with which variety of assimilation one ha 
to deal, as it is impossible to ascertain whether what corresponds to th 



Fig. 594. 



Fig. 595. 

Figs. 594- 



596. —High Assimilation Pelvis. 



first sacral vertebra is the twenty-fifth vertebra, as normal, or is the 
twenty-fourth or twenty-sixth vertebra, as the case may be. According 
to Rosenberg, in the' development of the pelvis the first portion of the 
sacrum to enter into the formation of the sacro-iliac joint is the twenty- 
sixth 'vertebra, which normally corresponds to the second sacral, the 
twenty-fifth vertebra not becoming involved until later. AccordinMv a 






















LOCALIZED AND ASYMMETRICAL ANOMALIES 


837 


tf sacrum with only four vertebrae may indicate the persistence of a foetal 
5 type, while the presence of six vertebrae shows that the normal process 
of articulation has been exaggerated. 

Assimilation is the most common of all pelvic abnormalities, and is 
a noted in at least every fifth or sixth pelvis; indeed Paterson noted it in 
' 38 P er cent - of all pelves which he studied. In a series of 217 Indian 
squaw pelves, Emmons stated that its incidence was 21.7 per cent. Un¬ 
less especially sought for, the condition is usually overlooked, so that 
it frequently happens that pelves which have been demonstrated for 
years by trained anatomists as typically normal present one or other 



Fig. 597. 


Figs. 597, 598. —Transversely Contracted Assimilation Pelvis (Breus and Kolisko). 

(type of this abnormality. Moreover, the condition may be associated 
Ivith rhachitis or general imperfect development, in which event one has 
[;o deal with rhachitic or generally contracted assimilation pelves (Fig. 
564). More commonly, however, such an association is lacking, but the 
mere existence of assimilation may, nevertheless, give rise to marked 
changes in the shape of the pelvis. 

When the last lumbar is assimilated with the first sacral vertebra— 
[high assimilation—so that the sacrum consists of 6 pieces, important 
[changes in the shape of the pelvis result, which depend in great part 
ipon the manner in which the sacrum and innominate bones articulate, 
is well as upon the width of the former. In some cases the condition 
^ives rise to a pelvis which is very high in its posterior portion, and 
ivhose superior strait is almost round, the walls of its inferior portion 
converging, thus producing a funnel-shaped pelvis (see Fig. 595). In 
Mher cases the condition gives rise to a pelvis with a somewhat trans- 
/ersely contracted superior strait (see Fig. 598), in which the conjugata 
/era is either relatively or absolutely longer than the transverse diame- 








838 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


ter. Fabre and Bourret have carefully studied this type of pelvis fror 
a clinical point of view, and state that it favors engagement of the hea 
with the sagittal suture directly anteroposteriorly, instead of oblique] 
as usual; so that it should be regarded as an essential factor in tb 
production of primary anterior or posterior occipital presentations. 

On the other hand, when the first sacral vertebra is assimilated wit 
the lumbar column-low assimilation—a pelvis results which is ver 
shallow in its posterior portion, hut which offers no particular obstacl 
to labor (see Fig. GOO). 

Occasionally the assimilated vertebra may undergo only a partia 
change, one side of it retaining the characteristics of a lumbar or sacra 
vertebra, as the case may he, while the other side undergoes consider 
able modification. Under such circumstances asymmetrical pelves resuli 
which are frequently obliquely contracted (see Fig. G01). 



Fig. 599.— Low Assimilation Pelvis (Breus and Kolisko). 


Funnel Pelvis.—Until recently, it was believed that the most char¬ 
acteristic examples of funnel-shaped pelvis are associated with lumbo¬ 
sacral kyphosis; and while contractions of the pelvic outlet are also 
noted in spondylolisthetic, osteomalacic, obliquely contracted, and other 
rare types of abnormal pelves, thejr occur so rarely that they are of 
scientific rather than practical importance, 

On the other hand, moderate degrees of outlet contraction are fre¬ 
quently noted under other conditions. Thus, in every fourth or fifth 
justominor pelvis the measurements of the inferior strait are diminished 
out of proportion to the rest of the pelvis, and occasionally to such an 
extent as to give rise to outlet dystocia. In such cases the diag¬ 
nosis of general contraction should inevitably direct one’s attention 
to the possible existence of the abnormality, so that it is not likely to 
pass unnoticed. 

Unfortunately, more or less serious contraction of the outlet fre¬ 
quently occurs in pelves which appear to he perfectly normal, so far 
as the usual pelvic measurements are concerned. Such pelves I have 
designated as typical funnel, in contradistinction to the generally con- 





LOCALIZED AND ASYMMETRICAL ANOMALIES 839 

tracted funnel variety to which reference has just been made. If outlet 
* pelvimetry is not made an integral part of the preliminary obstetrical 
1 ; examination, the former usually passes unnoticed unless the contraction 
I is so marked as to give rise to serious dystocia. In which event the 
physician may find himself in the embarrassing position of being obliged 
to resort to a radical operation in order to save the child, after having 
assured the patient that her pelvis was perfectly normal. 

Whenever the transverse diameter of the outlet measures 8 centimeters 
or less I designate the pelvis as funnel, and typical funnel pelves were 
noted in 6.1 per cent, of a series of 2,750 consecutive patients whom I 



Fig. 600.—Asymmetrical Assimilation Pelvis (Breus and Kolisko). 


examined up to April, 1911. In that series it was the most frequent 
abnormality observed in white women, making up 44 per cent, of the con¬ 
tracted pelves occurring in that race, and being almost as frequent as 
all of the other varieties combined. On the other hand, it constituted 
only 15 per cent, of the abnormal pelves in black women. Notwith¬ 
standing this marked difference in the relative ratio, its actual inci¬ 
dence in the two races was practically identical—5.87 and 6.43 per cent., 
respectively. 

Further investigation has confirmed these views; as Thoms, who 
studied a series of 4,000 women, who were delivered in my service up 
to the end of 1915 (cases 2,000-6,957), reported an incidence of 5.3 

per cent._4.96 in white and 5.76 in colored women, respectively. 

Furthermore, the fact that Emmons observed the abnormality in 9.2 
per cent, of 217 Indian squaw pelves indicates that its incidence is 
much greater than is generally believed. 

The fact that the incidence of typical funnel pelves is practically 
the same in black and white women is of great importance in deter- 










840 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 

mining their mode of production \ for, when it is remembered that ir 
my material the usual types of contracted pelvis occur five times mor 
frequently in the former than in the latter, it becomes evident tha 
outlet contractions must be due to some factor other than rhachitis o I 
imperfect general development, which play so conspicuous a pait ii 
the genesis of abnormal pelves in the colored race. Formerly it was 
believed that the condition was a manifestation of the existence of r| 
masculine or an infantile type of pelvis, but my observations have { 



Fig. 601.—Diagram Showing the Significance Pig. 602.—Diagram of Pelvic 
of Anterior and Posterior Sagittal Diam- Outlet of Same Case, Illus- 
ETERS. X l / z . TRATING POSSIBILITY OF SpON- 

Spontaneous labor through a transverse diameter taneous Labor Owing to Long 

of 5 5 cm Posterior Sagittal Diameter. 

X Vs- 

taught me that such is not the case, and I now believe that many outlet 
contractions, at least, are associated with high assimilation, namely, the 
presence of six vertebrae in the sacrum. This may so alter the relations 
at the sacro-iliac joints that the walls of the upper portion of the pelvic 
cavity converge, while the upper portion retains approximately its 
normal proportions. 

'The correctness of such a view is demonstrated by the fact that I was 
able to palpate six sacral vertebrae in a number of mv cases, and in 
many more to detect the existence of a false or second promontory. That 
definite proof could not be adduced in all cases is not surprising, as the 
sacral vertebrae can lie counted accurately on vaginal or rectal palpation 
in only a comparatively small proportion of cases. Nevertheless, I feel 
that the demonstration of the existence of high assimilation in a small 
number of living women justifies the assumption that it really occurs 
much more frequently. 

Earlier in this chapter attention was directed to Berry Hart s views 
on sexual inversion in the pelvis, when it was stated that he held that 
the existence of male characteristics in the ischiopubic portion, in asso- 























LOCALIZED AND ASYMMETRICAL ANOMALIES 


841 


ciation with, female characteristics in the iliosacral portion, would give 
rise to a funnel pelvis. I am not prepared to express an opinion upon 
this point, and it must be left to future research to determine the cor¬ 
rectness of his views. 

In the great majority of funnel pelves the shortening is limited 
to the transverse diameter of the pelvic outlet. Ordinarily this is reduced 
to between 7 and 8 centimeters, hut occasionally it is less, and in one 
of my patients it measured only 5.5 centimeters (Figs. 602 and 603). 
Exceptionally, the decrease in the distance between the tubera ischii 
may be associated with a shortening of the anteroposterior diameter of 
the outlet, which greatly increases the gravity of the condition, as will 
be indicated below. In still rarer instances, the contraction may be 



Fig. 603. —Diagram Showing the Significance 
of Anterior and Posterior Sagittal Diam¬ 
eters. X */ 3 . 

Cesarean section in spite of a transverse diam¬ 
eter of 6.5 cm. 



Fig. 604. —Diagram of Pelvic Out¬ 
let of Same Case, Illustrating 
Necessity for Cesarean Sec¬ 
tion. X A. 


limited to the anteroposterior diameter and this is usually associated 
with flattening at the superior strait ; although, of course, the most 
typical examples occur in the kyphotic and spondylolisthetic pelvis. 
Contractions of the latter type, however, are not classified as typical 
funnel pelves, but will be considered in their appropriate place. 

That contractions of the pelvic outlet may seriously affect the course 
of labor is shown by the fact that in 135 labors complicated by it and 
included in my paper of 1911, the following operations were necessary 
to effect delivery: namely, 17 forceps, 1 cesarean section, 3 pubiotomies, 
and 1 craniotomy upon the after-coming head. Moreover, even when 
the disproportion is not sufficiently great to give rise to serious dystocia, 
it may play an important part in the production of perineal tears. In 
such cases, with the increasing narrowing of the pubic arch, the occiput 
can not emerge directly beneath the symphysis pubis, and accordingly 
must stem itself further and further down upon the ischiopubic rami, 
and in extreme cases must rotate around a line joining the ischial 
tuberosities. Consequently the perineum must become more and more 
distended, and thus be exposed to greater danger of extensive rupture. 











842 


ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


In view of the frequency and practical significance of outlet con 
tractions, palpation of the pubic arch, as described in Chapter XXXII ! 
should form an integral part of the preliminary examination of ever 
pregnant woman. If any abnormality be detected the various diameter , 
of the pelvic outlet should be carefully measured. 

A shortening of the transverse diameter to 8 centimeters or less shoul 
be regarded as a danger signal; but, unfortunately, as Klien pointed ou I 
in 189G, the length of this diameter, either alone or in combinatioi 
with that of the anteroposterior diameter, does not afford a sufficien 
basis for the formulation of an intelligent prognosis. Thus, it may hap 
pen that serious dystocia may sometimes arise with a transverse diamete 



Fig. 605. —Diagram Illustrating Mensuration of the Anterior and Posterior 
Sagittal Diameters of Outlet by Means of Thoms’ Pelvimeter. X 1 /s- 


of 7.5 centimeters, while on the other hand spontaneous labor may occur 
when it is reduced to 5.5 centimeters, as in one of my cases (Figs. 602- 
605). 

This apparent discrepancy is readily understood when it is remem¬ 
bered that a decrease in length of the transverse diameter is associated 
with a progressive narrowing of the pubic arch, so that only a smaller 
and smaller segment of the head can pass beneath it, and in extreme 
cases only the portion of the outlet posterior to a line joining the ischial 
tuberosities is available for its passage. In such cases, it is evident that 
the possibility of delivery will depend not upon the actual length of the 
transverse or of the anteroposterior diameter, but rather upon the 
space available between the transverse diameter and the tip of the 
sacrum. 

Klien has designated this distance as the posterior sagittal diameter 
of the outlet, and devised a specially constructed pelvimeter for its 
mensuration. For years I obtained satisfactory results by the use of a 
modification of Klien’s instrument, which, however, had the disad¬ 
vantage that two persons were required for its manipulation, so that 
its employment was practically restricted to hospital patients. Thoms, 



















LOCALIZED AND SYMMETRICAL ANOMALIES 


843 



while working in my clinic, devised the instrument described in Chapter 
XXXIII, which can be manipulated by one person, and can be used for 
measuring the distance between the tubera ischii, as well as the anterior 
and posterior sagittal diameters of the outlet. 

For the latter purpose, the transverse bar of the pelvimeter is held 
by the fingers of one hand in relation with the transverse diameter of 
the outlet, while the end of the free blade is brought in contact with 
the tip of the sacrum—this gives the length of the external posterior 
sagittal diameter. The pelvimeter is then rotated, and the distance to 
the lower margin of the symphysis is determined—anterior sagittal 
diameter (Figs. 605 and 606). This latter varies between 5 and 6 


! Fig. 606. —Showing Mensuration of Anterior Sagittal Diameter of Outlet by 

Means of Thoms’ Pelvimeter. X V3- 

centimeters and is subject to comparatively little change; while the 
external posterior sagittal may vary greatly, and from it the length of 
the posterior sagittal may be estimated by deducting 1 centimeter the 

average thickness of the tip of the sacrum. 

In order for spontaneous labor to occur it is apparent that this 
diameter must increase proportionally in length as the tiansverse diame¬ 
ter of the outlet is shortened, and my observations show that it is un¬ 
likely with measurements less than the following: 

%J 

Transverse diameter 8 cm., posterior sagittal 7.5 cm. 

8 “ 

8.5 “ 

9 

10 “ 


< c 

4 i 

7 

4 4 

4 4 

4 C 

4 4 

i C 

6.5 

4 4 

4 4 

L 4 

t 4 

c c 

6 

4 4 

4 4 

4 4 

4 4 

i 

5.5 

4 4 

4 4 

4 4 








































































































844 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


It should, however, he understood that these are only approximate es - 
mates and by no means accurately indicate the necessity for radio 
interference, as spontaneous labor may occur when least expected. J 
multiparous women with a history of previous severe dystocia, they m; 
afford an indication for cesarean section or pubiotomy; while in primi 
arous women, if spontaneous labor does not occur, they should lead 1 
to substitute pubiotomy for brutal attempts at forceps delivery. 

In young women pubiotomy is the operation of choice whenever tl 
dystocia is serious, as it not only permits delivery at the time, but al: 

offers a reasonable prospect « 
permanently overcoming the a 
normality. In my article upc 
the effect of pubiotomy upon tl 
course of subsequent labors, 
have given details of several sue 
cases, and have shown that as tl 
result of the operation the funn< 
pelvis had become converted inf 
a normal one, or if this did nc 
occur that the softening an 
stretching of the fibrous union a 
the pubiotomy wound made pof- 
sible a temporary enlargemen 
sufficient to permit spontaneou 
labor. On the other hand, i: 
multiparous women who have al 
ready lost one or more children 
a>ai ean section at an appointed time should be chosen, as by so doin^ 
the birth of a living child will be assured, while with pubiotomy th* 
child will be exposed to a slight, but definite, risk. 

In moderate degrees of outlet contraction the effect of postural 
treatment should be tested before resorting to the use of forceps, as ] 
ha\e found that by placing the patient in an exaggerated Sims’ positioi 
the innominate bones rotate upon the sacrum to such an extent that the 
length of the posterior sagittal undergoes an average increase of 0.75 
centimeter, with extremes oi 0 and 4 centimeters. In minor degrees o: 
contraction, such an increase may be sufficient to do away with the 
necessity for the use of forceps. 

LITERATURE 



Fig. 607. —Diagram Illustrating Effect 
of Pubiotomy in a Pronounced Fun¬ 
nel Pelvis. Dotted lines show pubic 
arch before operation. X W 


Betschler. Neue Zeitschr. f. Geb., 1840, ix, 121. 

Boeckh. Ueber Zwergbecken. Archiv f. Gyn., 1893, xliii, 347-472. 

Breus und Kolisko. Die pat_i Beckenformen, 1900, i. Spaltbeeken, 107-13 
Assimilationsbecken, 169-256. Zwergbecken, 259-366. 

Budin. Reeherches experimentales a propos de l’ischio-pubiotomie. Femmes , 
couches et nouveau-nes, 1897, 468-482. 

Buttner. Besehreibung des inneren Wasserkopfs und des ganzen Beinkorne 

eincr von ] lei Geburt an bis im 31. Jahr krank gewesenen Person vveiblichi 
Geschlechts. Konigsberg, 1873. * 


/ 









LITERATURE 


845 


t Deventer. Neues Hebammenlicht. II. Aufl., 1728, 196. 

' Emmons. A Study of the Variations in the Female Pelvis, etc. Biometrika, 
I 1913, ix, 34-57. 

3 Eabre et Bourret. Bassin a diametre antposterieure predominant. Bull, de la 
; soc. d’obst, et de gyn. de Paris, 1913, xvi, 108-114. 

Gemmell and Paterson. Duplication of Bladder, Uterus, Vagina and Vulva, 
with Successive Full Term Pregnancy and Labor in Each Uterus. J. Obst. 
I and Gyn. Brit. Emp., 1913, xxiii, 25-32. 

Gonner. Zur Statistik der engen Becken. Zeitschr. f. Geb. u. Gyn., 1882, vii, 
314-331. 

Gurlt. Ueber einige Missgestaltungen des weiblichen Beckens. Berlin, 1854. 

I Hart. On Inversion of the Ilium and Sacrum and Ischium and Pubis as Causes 

of Deformities of the Female Pelvis. Edinburgh Med. Jour., 1916, xvi, 9-32. 

II Hohl. Das schragverengte Becken. Leipzig, 1852. 

Kaufmann. Untersuchungen iiber die sogenannte fotale Rachitis. Berlin, 1892. 
(■j Klien. Die geburtshiilfliche Bedeutung der Verengerungen des Beckenausgangs. 
■U Volkmann’s Samml. klin. Vortrage, 1896, N. F., Nr. 169. 

Kundrat. Quoted in full by Breus and Kolisko. Die path. Beckenformen, 1900, 
i, 147-153. 

Leisinger. Anat. Beschreibung eines kindlichen Beckens. D. 1., Tubingen, 1847. 

1 Litzmann. Das schragovale Becken. Kiel, 1853. 

Das gespaltene Becken. Archiv f. Gyn., 1872, iv, 266-284. 

Ein durch mangelhafte Entwickelung des Kreuzbeines querverengtes Becken. 
Archiv f. Gyn., 1885, xxv, 31-39. 

'll Martin, E. De pelvi oblique ovate. Jena, 1841. 

1 Miller. Complete Exstrophy of the Bladder with Split Pelvis as a Complication 
j of Pregnancy. Am. Jour. Obst., 1918, lxxvii, 267-273. 

, Muller. Zur Frequenz u. Aetiologie des allg. verengten Beckens. Archiv f. Gyn., 
j 1880, xvi, 155-173. 

Naegele. Das schragverengte Becken. Mainz, 1839. 

Olshausen. Schragverengtes Becken, etc. Monatssclir. f. Geburtsk., 1862, xix, 
161-185. 

Paltauf. Quoted in full by Breus and Kolisko. 

Paterson. The Human Sacrum. Scientific Trans, of the Royal Dublin Society, 
1893, v, 123-204. 

Pinard. De 1 ’ischio-pubiotomie ou operation de Farabeuf. Annales de gyn. et 
d’obst., 1893, xxxix, 139-143. 

Porak. De Uachondroplasie. Nouv. archives d’obst, et de gyn., Par., 1889, iv, 
551; 1890, v., 19; and following. 

Richelet. Du bassin generalement retreci, etc. These de Paris, 1896. 
Risciibeith and Barrington. Dwarfism. Eugenic Laboratory Memoirs, London, 
1912, xv. 

Robert. Beschreibung eines im hochsten Grade querverengten Beckens, etc. 
Karlsruhe u. Freiburg, 1842. 

Rosenberg. Ueber die Entwickelung der Wirbelsaule des Menschen. Morpho- 
logisches Jarbuch, 1876, i, 83-172. 

Bemerkungen fiber den Modus des Zustandekommens der Regionen in der 
Wirbelsaule des Menschen. Morphologisches Jahrbuch, 1907, xxxvi, 609-659. 
Schauta. Die Beckenanomalien. Mfiller’s Handbuch der Geb., 1889, ii, 220-496. 
ickele. Beitrag zur Lchre des normalen und gespaltenen Beckens. Beitrago 
zur Geb. u. Gyn., 1901, iv, 243-272. 

Stein. Lehrc der Geburtshfilfe, etc,, 1825, i, 78. 

Tarnier et Budin. Traite de l’art des accouchements, 1898, iii, 314-318. 







84(3 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 


Thomas, S. Das schagverentge Becken, etc. Leipzig, 1861. 

Thoms. A Statistical Study of the Frequency of Funnel Pelves and the Descrip 
tion of a New Outlet Pelvimeter. Am. J. Obst., 1915, lxxii, 121-132. 

Unna. Zur Genese des schragverengten Beckens. Hamburger Zeitse.hr. f. die 
ges. Med., 1843, xxiii, 281. 

Wagner. Ueber familiare Chondrodystrophia. Archiv f. Gyn., 1913, c, 70-134, 

Williams. The Etiology and Clinical Significance of Contractions of the Pelvic 
Outlet. Surg. Gyn. and Obst., 1909, viii, 619-638. 

The Funnel Pelvis. Am. J. Obst., 1911, lxiv, 106-124. 

The Effect of Pubiotomy upon the Course of Subsequent Labor. Am. J. Obst., 
1915, lxxii, 1-25. 

A Consideration of Some of the Factors Concerned in the Production of De¬ 
formed Pelves. Am. Jour. Obst., 1918, lxxvii, 714-758. 











CHAPTER XXXYI 


COURSE, PROGNOSIS AND TREATMENT OP PREGNANCY AND LABOR 

S COMPLICATED BY THE MORE COMMON FORMS OF CONTRACTED 
PELVIS 

Marked degrees of pelvic deformity exert a pronounced influence 
upon the course of pregnancy as well as upon the mechanism of labor. 
Indeed, to be unaccompanied by more or less definite effects the con¬ 
traction must be minimal. 


EFFECT OF CONTRACTED PELVIS UPON THE COURSE OF 

PREGNANCY 

The Position of the Uterus. —Very exceptionally in the early months 
of pregnancy a pronounced degree of pelvic malformation may interfere 
with the normal rising up of the uterus, particularly if the promontory 
of the sacrum projects so far into the superior strait as markedly to 
overhang the pelvic cavity. In these rare cases as the uterus increases 
in size it may assume a position of pronounced retroflexion, which later 
may give rise to characteristic symptoms of incarceration. 

Later in pregnancy, when the deformity is sufficient to interfere 
materially with the descent of the presenting part into the pelvis, marked 
abnormalities in the position of the uterus are observed. Particularly 
in primiparae, the fundus occupies a higher position than usual, and 
serious respiratory and circulatory disturbances often result. At the 
same time, owing to the fact that the lower portion of the uterus is not 
fixed by the engaged head, the entire organ is much more freely movable 
than usual. 

More important, however, is the sharply anteflexed position which 
the uterus may assume. This is particularly the case in small women 
presenting marked lumbar lordosis, whereby the capacity of the abdomen 
is so diminished that the growing uterus seeks to gain room by pushing 
forward the anterior abdominal walls. Consequently, the presence of a 
pendulous abdomen is a sign of considerable importance in primiparous 
women, and should always cause one to suspect the existence ot marked 
pelvic deformity. The converse, however, does not necessarily indicate 
that no disproportion exists. On the other hand, the same condition 
may have no great significance in multiparous women, being generally 
due to a loss of tonicity of the uterine and abdominal walls as a result 
of previous pregnancies. 

Position and Presentation of Foetus.— A contracted pelvis plays an 
important part in the production of abnormal presentations. In normal 

847 






848 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


primiparous women, the presenting part, as a rule, descends into th< 
pelvic cavity during the last six weeks of pregnancy; but when th( 
superior strait is considerably contracted this does not occur at all, 01 
not until after the onset of labor. Vertex presentations still predomi¬ 
nate; but since the head floats freely above the superior strait, or rest* 
upon one of the iliac fossae, very slight influences may cause the foetus 
to assume other positions. According to Michaelis, vertex presentations 
are rarer by 10 per cent, in contracted than in normal pelves; while 
face, breech, and transverse presentations occur 2 or 3 times, and prolapse 
of the cord and the extremities 4 to 6 times more frequently. 

That abnormal presentations increase in frequency with the degree 
of contraction, is shown by the following figures of Michaelis, Litzmann, 
and Schwartz: 


Conjugata vera 9.5—8.5 cm., 93.1% vertex presentations. 

“ “ 8.4—7.5 “ 83.8% “ 

“ “ 7.4 cm. or less, 64.7% il 11 

Tarnier, in 1,030 cases of labor complicated by contracted pelvis, 
observed the following incidence for the various presentations: vertex, 
85.13 instead of 96 per cent.; breech, 7 instead of 3 per cent.; face, 3 
instead of 0.6 per cent.; and transverse, 4.2 instead of 0.5 per cent. 

Since abnormal presentations occur more frequently in multiparous 
than in primiparous women even under favorable conditions, they be¬ 
come still more common when the pelvis is contracted. Thus, Schauta 
estimated that they are 3 times more frequent in the fifth than in the 
first pregnancy. 

In primiparous women face and transverse presentations possess a 
peculiar significance, as their occurrence is nearly always associated with 
serious disproportion between the size of the head and the pelvis, so that 
whenever either variety is encountered one can feel certain that the head 
is unusually large or the pelvis abnormally small. 

Size of Foetus.—La Torre, Pinard, and others have stated that the 
children of women with abnormal pelves usually attain a larger size than 
usual. Pinard attributes this to the fact that the head does not become 
engaged during the last few weeks of pregnancy, and therefore cannot 
press upon the lower uterine segment, thus doing away with one of the 
factors predisposing to the premature termination of pregnancy. Wilcke 
and Piggs, after careful study, have concluded that such is not the case, 
but that the children, in such circumstances, are generally slightly below 
the average in size. This is particularly the case with generally con¬ 
tracted pelves, as women possessing them are usually under-sized and 
would naturally produce smaller children than larger and better nour¬ 
ished individuals. 


MECHANISM OF LABOR IN RHACHITIC PELVES 

Ihe possibility of the occurrence of spontaneous labor in flat pelves 
depends primarily upon the degree of contraction, and, when this is not 
excesshe, upon Ihe following additional factors: the size, compressibility, 




MECHANISM OF LABOR IN RHACHITIC PELVES 849 

and malleability of the foetal head, and the character of the expulsive 
forces. The measurements of the pelvis can be determined with reason¬ 
able accuracy; with practice one can le'arn to estimate the size of the 
head with some degree of exactness, but there are no satisfactory methods 
of determining in advance the other properties of the head, and not 
until labor is well advanced can one predict even approximately what 
the uterus can do. 

In 701 cases of labor in contracted pelves, occurring in our service 
up to July, 1910, spontaneous delivery occurred in 74.16 per cent., and 
became progressively less frequent with increasing pelvic deformity. 
Thus, when the conjugata vera measured 


10 —9.6 cm. spontaneous delivery occurred in 85.1% 

9.5— 9.1 “ “ “ “ 78 5% 

9 —8.6 “ “ “ “ 61.3% 

8.5— 8.1 “ “ “ “ 37 8% 

8 —7.5 “ “ “ “ 29.4% 

7.5 cm. or less “ 11 “ 13.3% 


Even when delivery is effected spontaneously and without any undue 
delay, certain characteristic abnormalities can be observed in the 
mechanism of labor, by which the experienced obstetrician is enabled to 
recognize the presence of a flat pelvis without resorting to pelvimetry. 

Inasmuch as in the varieties of pelves under consideration the con¬ 
traction is practically limited to the anterior posterior diameter of the 
superior strait, while the transverse diameter is relatively large, it is 
evident that the obstacle to the passage of the child’s head must be 
offered by the shortened conjugata vera; and when this measures less 
than 9 centimeters it becomes* out of the question for the biparietal 
diameter of the head to pass through it, unless it undergoes some dimi¬ 
nution in size. Accordingly, when engagement is occurring, the head 
slips to one side so as to bring the shorter bitemporal diameter in rela¬ 
tion with the conjugata vera. As a result the long arm of the head 
lever becomes displaced to the side of the occiput, so that, under the 
influence of the uterine contractions, the anterior portion of the head 
descends, while the occipital portion rises up. Consequently the large 
fontanelle becomes more readily accessible to the examining finger on 
one 6ide of the pelvis, and the small fontanelle less so on the other. 
At the same time the head tends to accommodate itself to the transverse 
diameter of the superior strait, so that its long axis, as indicated by 
the sagittal suture, comes to lie transversely. 

More characteristic still is the abnormal attitude which the head 
assumes when the disproportion between it and the pelvis is at all 
marked, when we may have what is known as an anterior parietal pres¬ 
entation. In this the head assumes an eccentric position, so that the 
anterior parietal bone occupies the superior strait in such a manner 
that the sagittal suture lies just in front of the promontory. In such 
circumstances the anterior shoulder is readily distinguished upon ex¬ 
ternal palpation. According to the explanation generally accepted, this 
condition is brought about by the abnormal relation borne by the axis 
of the anteflexed uterus to the plane of the superior strait, as the result 





850 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


of which the posterior portion of the head is arrested against the prom¬ 
ontory of the sacrum, while its anterior portion is forced into the pelvis. 

This presentation is simply an exaggeration of the so-called Naegele’s 
obliquity, and the mechanism of descent is readily understood when 
we compare the passage of the head through the abnormal superior strait 
to the maneuver necessary to pass a stick of a certain length through a 
ring of a somewhat shorter diameter. To do so, one must depress one 
end of the stick so as to allow it to enter the ring obliquely, and after 
it has partially passed through its other end will descend without dif¬ 
ficulty. Sellheim suggests that this presentation provides a mechanism 
for effecting a diminution in the transverse diameter of the head. He 
considers that the sutures are so arranged that one lateral half of the 
head can be displaced to some extent beyond the other, just as in pushing 
one half of a jointed oval spring beyond its fellow the greatest transverse 
diameter will become considerably diminished. 




Fig. 608.—Showing Anterior Parietal, 
Presentation. 


Fig. 609.—Showing the Passage of an 
Anterior Parietal Presentation 
THROUGH THE SUPERIOR STRAIT. 


In order for descent to occur, the posterior parietal bone is firmly 
pressed against the promontory of the sarcum, while under the influence 
of the uterine contractions the anterior portion of the head is slowly 
forced down into the pelvis along the internal surface of the symphysis 
pubis; after this is accomplished the posterior portion passes over the 
promontory and enters the pelvis, the sagittal suture at the same time 
moving forward. Accordingly, when the contraction is marked, the 
posterior portion of the head must be subjected to considerable pressure, 
as is shown by the presence after birth of a more or less well-defined 
curved depression, just behind the coronal suture, upon the side of the 
head which was in contact with the promontory. After the posterior 
parietal bone has passed the superior strait, all resistance has been over¬ 
come, and, owing to the fact that the lower portion of the pelvis is 
relatively large, the rest of the labor is promptly accomplished. 

In about one-fourth of the labors occurring in flat pelves, according 
to Litzmann, the reverse condition—the posterior parietal presentation 





MECHANISM OF LABOR IN 11HACHITIC PELVES 


851 


* ls °bser\ed. sa g’ittal suture now lies almost in contact with the 
symphysis pubis, while the posterior parietal bone occupies the superior 
strait, and in pronounced cases the posterior ear of the child can be felt 
just above the promontory, so that the condition is sometimes spoken 
of as an ear presentation . The long axis of the child’s body forms an 



Fig. 610. —Showing Posterior Parietal 
Presentation. 



Fig. 611. —Showing the Passage of a 
Posterior Parietal Presentation 
through Superior Strait. 


obtuse angle with its head, and upon palpation the anterior portion of 
the latter can be felt as a prominent tumor lying above the symphysis. 

In this event, the head cannot enter the pelvis until its posterior por¬ 
tion is pushed down past the promontory of the sacrum, after which its 
anterior portion descends along the symphysis pubis, while at the same 
time the sagittal suture approaches the mid-line of the pelvis. After 
this has occurred labor takes place in the usual manner. 

The mode of 
production o f 
this abnormality 
is not definitely 
understood, al¬ 
though it is ob¬ 
served most fre¬ 
quently when the 
grade of contrac¬ 
tion is marked, 
the pelvic inclin¬ 
ation consider¬ 
ably increased, 
and the abdomen 
not pendulous It 

is generally considered as very unfavorable by the Germans, as the line 
along which the uterine contractions are transmitted is given another 
direction at the neck, which is much less advantageous than when the 
spinal column and head form a continuous axis. Tarniei, and Marnier, 
on the other hand, hold that the posterior parietal presentation occurs 


















852 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


more frequently than the anterior, and is without ominous prognostic 
significance. In my experience, however, it has occurred far less fie- 
quently, although in certain cases it has not been associated v ith a 
particularly difficult labor. 

When the promontory of the sacrum protrudes into the superior strait 
in such a way as to render it reniform in outline, it is impossible for 
the head to assume its usual transverse position, and the sagittal suture 
must occupy an oblique diameter (Fig. 612). In rare instances the 
deformity is so great that the superior strait resembles the figure 8. 
In such circumstances only one side of it is available for the passage 
of the head, and Breisky has designated the condition as extramedian 
engagement. It naturally serves to exaggerate the degree of dispro¬ 
portion. 

Breech presentations likewise complicate matters to some extent, as 

the imperfect adaptation of the 
breech to the superior strait fre¬ 
quently facilitates prolapse of the 
cord or of one or more of the ex¬ 
tremities. In such circumstances, 
although the prognosis for the 
mother remains favorable, the 
child’s life is endangered. This is 
especially true when the contrac¬ 
tion is marked, as considerable 
difficulty may be experienced in ex¬ 
tracting the after-coming head, 
which, in passing through the con¬ 
tracted superior strait, follows a 
mechanism analogous to that ob¬ 
served in anterior parietal presen¬ 
tations. In other words, its posterior portion is arrested at the promon¬ 
tory, while its anterior portion passes down behind the symphysis, after 
which its posterior portion descends. 

In generally contracted flat pelves the mechanism of labor varies 
according to the extent of the deformity and the shape of the pelvis— 
that is, according as it approaches more closely to the flat or to the 
generally contracted type. In the former case, provided the contraction 
be not too marked, the mechanism of labor will be identical with that 
just described for flat pelves, whereas in the latter the head will become 
sharply flexed and be born by the mechanism to be described below. 

In the generally and equally contracted rhachitic pelvis the mechan¬ 
ism corresponds to that observed in the justominor pelvis; while in the 
pseudo-osteomalacic forms the contraction is usually so marked that the 
child cannot be born per vias naturales. 

The effect of the generally contracted, or justominor, pelvis upon 
the course of labor is ver}^ characteristic. Owing to the fact that all 
of the diameters of the superior strait are shortened, the head encounters 
more or less equal resistance from all sides of the pelvic outlet, conse¬ 
quently it enters it in an oblique diameter and in a sharply flexed 



Fig. 013. —Showing Passage of After¬ 
coming Head through Superior 
Strait; Darker Child Last. 












COURSE OF LABOR IN CONTRACTED PELVIS 853 

position, so that on vaginal examination the small fontanelle is readily 
felt, while the large fontanelle is almost or quite out of reach. More- 
o\ei, as the contiaction involves all portions of the pelvic canal, labor 
is not lapidly completed after the head has passed the superior strait. 
The pi elongation is due not only to the resistance offered by the pelvis, 
but also in many instances to the faulty character of the uterine con¬ 
tractions, incident to the imperfect development of the uterus, which 
frequently characterizes such patients. 

In typical funnel pelves no difficulty is experienced until the head 
reaches the pelvic floor and attempts to pass through the narrowed 
pubic arch. The details of this mechanism were considered in the 
preceding chapter and need not be recapitulated. 


COURSE OF LABOR IN CONTRACTED PELVIS 

When the pelvic deformity is not absolute, but is sufficiently pro¬ 
nounced to prevent the head from entering the superior strait during 
the last few weeks of pregnancy, or at the onset of uterine contractions, 
the course of labor is usually unduly prolonged. In the first stage this 
is due to imperfect dilatation of the cervix, and in the second to the 
time required so to mold and configure the head as to render possible 
its passage through to the pelvic cavity. 

Abnormalities in Dilatation of Cervix. —Normally, dilatation of the 
cervix is brought about by the unruptured membranes acting as a hydro¬ 
static wedge, and after their rupture by the direct action of the present¬ 
ing part. In contracted pelves, on the other hand, when the head is 
arrested at the superior strait, the entire force exerted by the uterus acts 
directly upon the portion of membranes in contact with the internal os, 
and, consequently, as the force is not broken by the intervening head, 
as in normal labor, premature rupture frequently results, occurring, 
according to Litzmann, in 26 per cent, of the cases. 

After rupture of the membranes, further dilatation cannot take place 
until the presenting part is able to exert a direct pressure upon the 
cervix, and this is out of the question until a succession of strong pains 
have molded the head sufficiently to permit its descent, or have led to 
the formation of a caput succedaneum upon its most dependent portion. 

Even after the cervix is completely dilated further delay may occur, 
and it sometimes requires hours to mold the head to the pelvis. In 
flat pelves the labor is promptly terminated as soon as the contracted 
superior strait is passed, but in the generally contracted varieties this is 
not the case, inasmuch as the hindrance persists throughout the entire 
pelvic canal. 

Abnormalities in Uterine Contractions. —In many instances the 
course of labor is still further prolonged owing to faulty uterine con¬ 
tractions. This is rarely the case in rhachitic primiparae, in whom the 
pains are usually very efficient; hut in multiparae, in whom previous 
difficult labors have weakened the uterine musculature, secondary uterine 
inertia frequently occurs as the result of exhaustion. 





854 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


On the other hand, the uterus may become tetanically contracted. 
This is an extremely serious condition, as it cannot lead to the termina¬ 
tion of labor, and at the same time markedly increases the danger of 
uterine rupture. If this complication does not yield promptly to the 
administration of sedatives, it affords an imperative indication for the 
termination of labor. 

Danger of Uterine Rupture.—Abnormal thinning of the lower uterine 
segment frequently constitutes a very serious danger during a prolonged 
second stage. When the disproportion between the head and the pelvis 
is so pronounced that engagement and descent do not occur, the lower 
uterine segment becomes more and more stretched, and the danger of 
rupture becomes imminent. In such cases the contraction ring can be 
felt as a transverse or oblique ridge extending across the uterus some¬ 
where between the symphysis and the umbilicus, while sometimes its 
position is clearly visible. Thinning of the lower uterine segment is 
particularly liable to occur in the generally contracted variety of rhachitie 
pelvis, since the lower end of the cervix may be caught between the 
child's head and the pelvic brim, and thus be prevented from retracting. 
Whenever this condition is noted prompt delivery is urgently indicated; 
but at the same time great caution is necessary on the part of the 
physician lest his maneuvers give rise to traumatic rupture. 

Production of Fistulae.—When the presenting part is firmly wedged 
into the superior strait, but makes no advance for a long time, portions 
of the birth canal lying between it and the pelvic wall may be subjected 
to undue pressure. As a result the circulation is so interfered with 
that necrosis follows, which may manifest itself a few days after labor 
by the appearance of vesicovaginal, vesicocervical, or rectovaginal fistulae, 
depending upon the part involved. These conditions are not to be 
feared so long as the membranes remain intact, but are liable to follow 
a very prolonged second stage. 

Intrapartum Infection.—Infection is another serious danger to which 
the patient is exposed in prolonged labors complicated by premature 
rupture of the membranes, particularly when examined repeatedly by 
those who do not observe stringent aseptic technic. If the amniotic : 
fluid becomes infected, febrile symptoms appear during labor, while in 
other cases the microorganisms pass through the foetal membranes and 
invade the uterine walls, giving rise later to the characteristic manifesta¬ 
tions of puerperal infection. 

In other instances gas-producing bacteria may gain access to the 
uterus, which soon becomes distended with gas as a result of their 
activity —tympanites uteri or physometra. This condition usually fol¬ 
lows infection with bacillus aerogenes capsulatus, particularly when the 
child is dead. It was formerly attributed to the entrance of air into 
the uterus, but at present such an explanation must be regarded with 
skepticism. For further details the reader is referred to the chapter 
upon Puerperal Infection. 

Rupture of the Pelvic Joints.—In rare instances, particularly when 
fhe pelvis is contracted in its lower portion, spontaneous rupture of the 
symphysis pubis or of one or both sacro-iliac joints has been observed. 







855 


COURSE OF LABOR IN CONTRACTED PELVIS 

Such cases have been reported by Ahlfeld, Schauta, Braun-Fernnwald, 
De Lee, Kehrer, and others, though in the majority the injury is pro¬ 
duced by injudicious methods of delivery. Kehrer in 1915 collected 
tiom the literature 100 cases of rupture of the symphysis pubis, 17 of 
which occurred during the course of spontaneous labor. He considers 
Uiat the predisposing cause for the accident consists in unusual softening 
oi Hie development of cavities in the pubic cartilage. 

Effect of Labor upon the Child.—So long as the membranes remain 
intact the child suffers but little from the prolonged labor; but after 
Iheii ruptuie, continued uterine contractions may exert a deleterious 
influence upon it. This is due in great part to interference with the 
placental circulation, which sooner or later leads to manifestations of 
asphyxiation. Now and again premature separation of the placenta 
occurs, causing certain death to the child. 

Particularly during the second stage of 
labor, prolonged pressure exerted upon the 
head is not without influence upon the 
child, in some cases leading to vagus 
stimulation with its resulting slow pulse 
and consequent gradual asphyxiation. 

Prolapse of the Cord.—A much more 
serious and frequent complication for the 
child is prolapse of the cord, the occur¬ 
rence of which is facilitated by imperfect 
adaptation between the presenting part 
and the pelvic inlet. The condition exerts 
no influence upon the course of labor, but 
in the majority of cases death of the child 
results from compression of the cord be¬ 
tween the presenting part and the pelvic 
wall, unless prompt delivery can lie ac¬ 
complished. This must be regarded as 
one of the most frequent causes of foetal death in spontaneous labor in 
contracted pelves. 

Changes in Scalp and Skull.—As has already been stated, a marked 
caput is frequently developed upon the most dependent part of the head, 
and allusion has been made to the part which it sometimes plays in the 
dilatation of the cervix. In many instances it may assume very con¬ 
siderable proportions, and lead to serious diagnostic errors. For example, 
it may project almost to the pelvic floor while the head is still above the 
brim, so that an inexperienced physician may mistake it for the head and 
thus be tempted to resort to ill-timed operative measures. Such a caput 
is without significance so far as the life of the child is concerned, and 
disappears within a few days after birth. 

When the disproportion between the size of the head and the pelvis 
is considerable, it is apparent that the former can only pass through 
after a process of molding and accommodation, which is usually spoken 
of as configuration. In exceptional cases the head may descend into 
the pelvic cavity comparatively early in pregnancy, and, as it cannot 



Fig. G14. —Showing Molding 
or Head in a Generally 
Contracted Rhachitic Pel¬ 
vis. 


856 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 

readily escape, it undergoes further development in that position, and m 
consequence presents characteristic deformities at birth, the pai wi m 
the pelvis being markedly flattened, while that above is unusually large, 

as shown in Fig. 614. 


Fig. 



615. —Overlapping of Bones of 
Skull (Tarnier). 


Fig. 616. —Overlapping of Bones of 
Skull (Tarnier). 



Under the influence of the strong uterine contractions the various 
bones comprising the skull come to overlap one another at the various 
sutures. As a rule the median margin of the parietal bone, which is in 

contact with the promontory, be¬ 
comes overlapped by that of its 
fellow, and the same occurs with 
the frontal bones. The occipital 
bone, on the other hand, becomes 
shoved under the parietal bones, 
so that the posterior margins of 
the latter frequently overlap it. 
These changes are usually ac¬ 
complished without detriment to 
the child, though when the dis¬ 
tortion is marked they may lead 
to tentorial tears, and, when 
vessels are involved, to fatal in¬ 
tracranial hemorrhage. 

Coincident with the molding 
of the head, the parietal bone, 
which was in contact with the 
promontory, may show signs of 
having been subjected to marked pressure, sometimes becoming very 
much flattened. Configuration is more readily accomplished when the 
bones of the head are imperfectly ossified, in rare instances the skull 
being so soft that it yields to pressure as readily as the shell of a soft 
crab. This process is of great importance, and serves to explain the 
difference in the course of labor in two apparently similar cases in 
which the pelvis and the head present identical measurements. In the 
one the head is soft and readily molded, so that spontaneous labor can 



Fig. 617. —Child Born Spontaneously 
through Generally Contracted Rha- 
chitic Pelvis, Conjugata Vera 7.25 
Centimeters Showing Caput Succedan- 
eum and Depression of Skull. 














COURSE OF LABOR. IN CONTRACTED PELVES 


857 


result; in the other the more resistant head retains its original shape, 
and radical operative interference becomes necessary for its delivery. 

Reference has already been made to the pressure marks upon the 
scalp covering the portion of the head which passes over the promontory 
of the sacrum. These are very characteristic in appearance, and from 
their location frequently enable one to determine the movements which 
the head has undergone in passing through the superior strait. Much 
more rarely similar marks appear on the portion of the head which 
has been in contact with the symphysis pubis. Such marks have no 
influence upon the well-being of the child, and usually disappear a few 
days after birth, although in exceptional instances the pressure may 
have been so severe as to lead to necrosis and sloughing of the scalp. 

Fractures of the skull are occasionally met with, and usually follow 
forcible attempts at delivery, though occasionally they may occur spon¬ 
taneously. The fractures are of two varieties, appearing either as a 
shallow gutterlike groove or as a spoon-shaped depression iust posterior 



Fig. 618. —Pressure Marks from Prom¬ 
ontory. 


Fig. 619. —Spoon-Shaped Fracture of 
Skull (Tarnier). 


to the coronal suture. The former is relatively common, and, as it 
involves only the external plate of the bone, is not very dangerous; 
whereas the latter, if not operated upon, leads to the death of the child 
in about 50 per cent, of the cases; since it extends through the entire 
thickness of the skull and gives rise to projections upon its anterior, 
which exert injurious pressure upon the brain. In such cases it is 
advisable, as soon as convenient after labor, to elevate or remove the 
depressed portion of the skull, as may be indicated, in the hope of 
preventing pressure symptoms. 

Prognosis for the Mother.—The prognosis as to the outcome of labor 
complicated by contracted pelvis depends not only upon the degree of 
contraction, but also upon the other factors to which we have already 
alluded. It may be said, however, that spontaneous birth of a fully 
developed child cannot occur when the conjugata vera measures 7 centi¬ 
meters or less, and is very unlikely when it measures 7.5 centimeters. 
Above the latter limit it becomes increasingly frequent as the degree of 
pelvic distortion diminishes. 

In our series of 701 cases studied in 1910, not including funnel 
pelves, 74.76 per cent, of the children were born spontaneously, and the 


858 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


incidence increased to 81.75 per cent, when the deliveries by low forceps 
were deducted, in which the operation had naturally no connection with 
the pelvic deformity. These results compare very favorably with those 
of other clinics, as is shown by the following figures: 

Valency. 69 percent. Burger. 77.8 per cent. 

Peham. 72.4 per cent. Kronig. 78.5 per cent. 

Bar. 76.5 per cent. Baisch. 80 percent. 

The probability of spontaneous labor decreases rapidly with the 
degree of pelvic contraction, as is shown by the following analysis of 
our cases, in which the second column gives the total incidence, and the 
third column the corrected incidence, which was obtained by deducting 
all operations not due to pelvic indications: 


Conjugata Vera 
(Obtained by deducting 1.5 cm. 
from Diagonal Conjugata) 

Number 

of 

Cases 

Spontaneous 

Labor, 

Gross 

Spontaneous 

Labor, 

Corrected 

10 -9.6 cm. 

248 

85.1% 

94.0% 

9.5-9.1 cm. 

270 

78.5% 

84.3% 

9 -8.6 cm. 

111 

61.3% 

67.6% 

8.5-8.1 cm. 

37 

37.8% 

37.8% 

8 -7.6 cm. 

17 

29.4% 

29.4% 

7.5 cm. or less. 

15 

13.3% 

20.0% 


Furthermore, if the length of the conj ugata * vera be calculated by 
deducting 2, instead of 1.5, centimeters from the diagonal conjugate, 
as is done by most writers, our results appear still more favorable, as 
is shown by the following tabulation: 


Conjugata Vera 

Burger 

in 

5,288 Cases 

Peham 

in 

885 Cases 

Baisch 

in 

927 Cases 

Williams 

in 

701 Cases 

10 -9.6 cm. 

89 % 

89 % 

94 

% 

•• % 

9.5-8.6 cm. 

80 % 

80.5% 

90 

% 

89.8% 

8.5-7.6 cm. 

54.4% 

63.8% 

65 

% 

60.1% 

7.5 cm. or less... 

9.9% 

14.8% 

18 

% 

25 % 


Generally speaking, the probability of spontaneous labor is somewhat 
less in generally contracted than in flat pelves presenting the same con- 
jugata vera, it being customary to calculate that half a centimeter must 
be added to the conjugata vera of the former to make it comparable to 
the latter. This, however, is denied by Baisch, and Zangemeister, and 
in my own experience, the expected difficulty is usually compensated for 
by the somewhat smaller size of the children. 

The danger to the mother depends upon the course of labor, the 
perfection with which aseptic technic is observed, and the treatment 
pursued in operative cases. Speaking broadly, the maternal mortality 
<iftoi spontaneous labor should be hardly greater than in normal pelves. 






































COURSE OF LABOR IN CONTRACTED PELVIS 


859 


if the case is conducted properly. On the other hand, if spontaneous 
labor does not occur, and the patient is left to herself, she will die 
undelivered, either from hemorrhage resulting from uterine rupture or 
from infection. In operative cases the prognosis depends entirely upon 
the choice of the operation, the surroundings of the patient, and the 
degree of perfection of the technic. 

In our 701 cases of labor complicated by contracted pelvis there were 
11 maternal deaths (1.57 per cent.). It should be said, however, that 
4 of these patients were profoundly infected when first seen, as the 
result of attempts at delivery outside of the hospital, and that uterine 
cultures taken at the time of delivery demonstrated the presence of the 
microoganisms which caused the fatal infection, leaving a net mortality 
of 1.0 per cent. 

Bar had one maternal death in 166 cases and Baisch four deaths in 
809 cases, a mortality of 0.59 and 0.50 per cent, respectively. Ludwig 
and Savor reported a mortality of 0.8 per cent, in 706 spontaneous 
labors complicated by contracted pelvis, as compared with 5.2 per cent, 
in 591 operative cases. These results were obtained after aseptic technic 
had become so perfected that radical operations could be undertaken 
with comparative safety; previously they were impossible, as Michaelis, 
and Litzmann reported a mortality of 10 per cent, and 7.3 per cent., 
respectively. 

A very instructive comparison between the conditions existing then 
and now was furnished by Tarnier, who stated that in 334 cases occur¬ 
ring in the Maternite in Paris between the years 1860 and 1869, the 
maternal mortality was 22 per cent., as compared with 1.91 per cent, 
in 1,036 cases occurring between 1884 and 1892. In the latter series 
the mortality was 0.78 per cent, in spontaneous, and 5.15 per cent, in 
operative deliveries. 

Prognosis for the Child.—The prognosis for the foetus is always more 
serious in contracted than in normal pelves, even though labor occurs 
spontaneously. It likewise depends to a great extent upon the methods 
chosen for delivery, and, broadly speaking, increases with the degree of 
pelvic contraction, unless cesarean section or pubiotomy is frequently 
performed. This is clearly shown by the following table of Michaelis, 
Litzmann, and Schwartz: 

Coniugata vera 9.25—8.5 cm., foetal mortality 5 % 

“ “ 8.4 —7.5 “ “ “ 16.9% 

“ “ 7.4 —7 “ “ “ 52.9% 

In a series of 1,297 cases studied by Ludwig and Savor, the mortality 
was 9.4 per cent, in spontaneous, and 46.3 per cent, in operative labors; 
while Bar, and Baisch reported a mortality of 11 and 23 per cent., and 
of 3.3 and 29.8 per cent., respectively, in similar series of cases. This 
striking difference is due to the fact that Ludwig and Savor resorted to 
craniotomy in the difficult cases, while Bar and Baisch performed 
cesarean section or pubiotomy whenever indicated. 

In our series of 701 cases, 68 children were born dead or died within 
two weeks after delivery, a gross mortality of 9.7 per cent. As 12 of 


860 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


them were macerated and 21 others died from various conditions not 
connected with the pelvis, the actual number succumbing to the pelvic 
complication was 35. Of these 7 were dead when the mother was ad¬ 
mitted to the hospital, having succumbed as the result of operative 
measures undertaken outside, leaving 28, or 4 per cent., who died in 
our hands, as compared with Baisch’s corrected mortality of 4.5 per cent. 


TREATMENT OF LABOR COMPLICATED BY CONTRACTED 

PELVIS 

The treatment of labor complicated by contracted pelves varies ac¬ 
cording to the degree of contraction, the size of the child, and the history 
of previous labors. Generally speaking, a normally developed full-term 
child cannot be born spontaneously when the conjugata vera measures 
7 centimeters or less, and only exceptionally when it falls below 7.5 
centimeters; whereas, interference is rarely required when it measures 9 
centimeters or more. 

We have therefore to consider in the first place the treatment of 
two great groups of pelvic deformities—those in which the conjugata 
vera measures 7.5 centimeters or less, and those in which it measures 
more. In the first group the problem is camparatively simple, whereas 
in the latter it is ofttimes extremely complex and requires the utmost 
nicety of judgment for its proper solution. 

Conjugata Vera of 7.5 Centimeters or Less.—It is customary to con¬ 
sider that a flat pelvis with a conjugata vera of a certain length gives 
rise to the same degree of dystocia as a generally contracted pelvis with 
one a half centimeter longer. For example, a flat pelvis of 7 centimeters 
would be equivalent to a generally contracted one of 7.5 centimeters; 
but, as this has not been my experience, I shall not make the distinction. 

If the deformity is recognized during pregnancy, the patient should 
be sent to a well-regulated hospital for the performance of cesarean 
section within a few days of the expected date of confinement or at the 
onset of labor, as the operator deems best. Such a procedure will give 
almost ideal results, and all of the children and 99 per cent, of the 
mothers should be saved, inasmuch as the maternal mortality following 
cesarean section, when performed upon healthy women by competent 
operators at an appointed time, need not exceed that following the 
removal of uncomplicated ovarian cystomata. 

On the other hand, if the condition of the pelvis has not been 
recognized until the woman is well advanced in labor, the treatment to 
be pursued will vary with circumstances. If the patient is uninfected, 
has not been examined repeatedly by the vagina, and is in suitable 
surroundings, cesarean section will offer every prospect for saving the 
child, provided it is in good condition, but the chances for the mother 
will be 5 or 10 per cent, less than if the operation had been done at 
an appointed time. But if the patient is infected or in poor condition, 
or the child is dead or dying, the treatment to be pursued will be 
determined by the degree of pelvic contraction. If the conjugata vera 


TREATMENT OF LABOR IN CONTRACTED PELVIS 


861 


be above 5.5 centimeters, craniotomy is the operation of choice; but 
with a measurement below this limit we have to deal with the absolute 
indication for cesarean section, which should be performed, no matter 
what the condition of the child or the mother, as in such circumstances 
the delivery of a mutilated child through the natural passages will be 
impossible, or at least quite as dangerous to the mother as a cesarean 
section done under unsatisfactory conditions. In infected cases the 
delivery of the child should be followed by a total hysterectomy. Pubi- 
otomy should not be thought of here, as its field of usefulness is limited 
to pelves in which the conjugata vera exceeds 7 centimeters, and to 
uninfected women with live children. 

Conjugata Vera above 7.5 Centimeters.—Here the question as to the 
proper treatment cannot be so readily disposed of, since definite rules 
cannot be laid down for the entire group, and each case must be con¬ 
sidered upon its own merits. 

We know in general that spontaneous labor will occur in many of 
these cases, and that its probability increases progressively with each half 
centimeter’s increase in length of the conjugata vera. But at the same 
time it may be difficult to predict what will occur in an individual case, 
as we have to reckon not only with the degree of pelvic deformity, but 
also with the size of the child’s head, the extent to which it may become 
molded and compressed, and the character of the labor pains. Moreover, 
although we can determine the size of the pelvis with considerable 
accuracy, and that of the child with some accuracy, unfortunately we 
can form only a very imperfect estimate concerning the other factors; 
and until methods are devised by which this becomes possible, the treat¬ 
ment of labor complicated by moderate degrees of contraction will remain 
a difficult problem. Of course, the ideal to be striven for is the attain¬ 
ment of such prognostic proficiency as to be able to determine with 
certainty before the onset of labor whether the disproportion can, or 
cannot, be overcome by the unaided efforts of Nature, and in the formei 
event to count confidently upon a spontaneous outcome, or in the lattei 
to perform cesarean section at an appointed time a few days before 
the calculated end of pregnancy. Naturally, this is out of the question, 
but it is nevertheless possible to develop such skill in prognosis that 

relatively few mistakes will be made. 

Methods of Determining the Size of the Head.—Despite the existence 
of numerous methods devised for determining the size of the head, we 
are still without one that is thoroughly satisfactory. 

In multiparous women, important information can occasionally be 
gained from the character of the heads of the children born in previous 
labors. If they were large and firmly ossified, it is probable that the 
child in question will possess a head showing similar characteristics, 
or may even be somewhat larger, as it is well known that the size is 

liable to increase with the age of the mothei. 

Ao-ain, Muller’s method of impression often affords material aid. In 
this procedure, the patient having been anesthetized, the obstetrician 
seizes the brow and occiput of the child with his fingers through the 
abdominal wall and makes firm pressure downward in the axis of the 


862 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


superior strait, the effect of which may be controlled by the fingers of 
an assistant in the vagina. If there be no disproportion, the head will 
readily enter the pelvis and spontaneous labor may be predicted. On 
the other hand, the fact that the head cannot be forced into the superior 
strait does not necessarily indicate that spontaneous labor is out of 



Fig. 620. —Method of Determining Degree of Disproportion by Ascertaining the 
Extent to which the Head Overrides the Symphysis. 


the question, as we have no means ^of foretelling the extent to which 
molding and configuration will occur at the time of labor. 

Munro Kerr employs the following method, which has the advantage 
of not requiring the services of an assistant. The obstetrician takes 
the Pawlik grip of the foetal head with his right hand and presses it 





TREATMENT OF LABOR IN CONTRACTED PELVIS 


865 


an hour or so of second-stage pains, or at least becomes sufficiently 
molded to permit the safe application of mid forceps. 

On the other hand, if engagement fails to occur after complete 
dilatation of the cervix, the patient should be placed in Walcher’s 
position tor as long a time as she will bear it. In many cases this 
procedure will bring about a lengthening of the anteroposterior diameter 
of the superior strait sufficient to permit engagement. As soon as the 
head has descended into the pelvis, the patient should be placed upon 
her back, as the hanging position tends to contract the pelvic outlet 
and thus retards delivery. If this does not bring 'about the desired 
result, or the child is unusually large, the treatment outlined in the 
following section should be adopted. 

If the child should die during the course of labor, craniotomy should 
be resorted to without hesitation, as it is safer for the mother than the 
application of high forceps. 

Conjugata Vera 9 to 7.5 Centimeters.—It is in “border line” pelves, 
contracted within these limits, that the greatest difficulty is experienced 
in predicting the course of labor and in laying down rules for treatment. 
More than one half of such patients will be delivered spontaneously, 
the number decreasing as the lower limit is approached; but it is often 
impossible to foretell what will occur in a given case. Consequently, 
the patient should be examined most carefully at the end of pregnancy 
for the purpose of determining the existence and degree of disproportion. 
If it is clearly evident that the child’s head will not engage, or if the 
history of previous labors renders it probable that a spontaneous termi¬ 
nation is out of the question, cesarean section should be performed at 
an appointed time. On the other hand, if the disproportion appears 
to be so moderate that it is reasonably certain that a second stage of 
average intensity will bring about such configuration that the head 
will enter the pelvis, the labor should be left to Nature in the hope 
that it will end spontaneously. It should always be remembered in 
this type of case that the ideal is to be able to differentiate before the 
onset of labor between the patients who require cesarean section and those 
in whom spontaneous labor can occur. Whenever a tentative course is 
pursued, the most rigorous aseptic technic should be employed, and 
the progress of labor followed by palpation and rectal touch, internal 
examination being restricted as far as possible. If the condition of 
the pelvis has been ascertained before labor, a vaginal examination need 
not be made, unless some emergency arises, oi the second stage is unduly 
prolonged. The foetal heart, of course, should be auscultated at frequent 

intervals 

In a large number of cases spontaneous delivery will occur after a 
longer or shorter second stage; but if the prognosis has been incorrect, 
and"the head shows no tendency to descend after several hours of efficient 
second-stage pains, a spontaneous termination can scarcely be hoped for, 
and it then remains to determine what will be the most desirable method 

of delivery. 

If the patient is in a well-regulated hospital, and the head is still 
above the superior strait, and shows no sign of engaging, pubiotomy 


866 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 

or cesarean section should be considered, according to the preference of 
the operator; although my experience leads me to believe that in such 
circumstances the former is preferable, as its mortality at this time 
is considerably less than that of cesarean section. After the patient 
has been anesthetized, but before proceeding to operate, a thorough 
vaginal examination should be made with the entire hand, and the size 
and character of the head estimated. If there seems to be no likelihood 
of engagement occurring, the operation should he proceeded with, but 
in other cases it should be deferred. 

On the other hand, if the patient be in a tenement house and refuses 
to enter a hospital, or is in the country where the physician cannot 
command the necessary assistance and appliances for an aseptic opera¬ 
tion, the second stage should be allowed to continue until the appear¬ 
ance of definite signs of danger on the part of the mother or child. 
Occasionally spontaneous labor will occur contrary to all expectation. 
Failing such a fortunate outcome, high forceps should be applied 
obliquely to the head and a few tractions made. If the head shows a 
tendency to advance, they should be persisted in, but if not, the instru¬ 
ment should be removed and craniotomy performed. In such cases 
forceps should be employed only tentatively , it being understood that 
its employment is generally contra-indicated, and that prolonged traction 
and brutal methods of extraction are not permissible, as by their means 
the child is almost as surely lost as by craniotomy, while the life of 
the mother is unnecessarily endangered. 

Of course, if the patient is a devout Catholic, the well-known views 
of that Church concerning craniotomy must be recognized, and the 
physician may be called upon to perform pubiotomy or cesarean section 
when, from a purely professional point of view, its justifiability might 
be open to criticism. In all but the slightest grades of contracted pelvis, 
craniotomy should be performed whenever the child has died during the 
course of labor, as any other operation subjects the mother to increased 
danger for the purely sentimental consideration of not mutilating the 
child. 

Furthermore, if the patient has not been seen until far advanced in 
labor, and has been repeatedly examined by persons not skilled in aseptic 
technic, or if she presents symptoms indicative of a beginning infection, 
pubiotomy or conservative cesarean section is contra-indicated on account 
of their very high mortality in such circumstances. If, however, the 
patient is very anxious for a living child, cesarean section followed by 
supravaginal hysterectomy is justifiable, as experience shows that the 
results following it are excellent. It should always be remembered that 
this operation entails permanent sterility, so that in making a decision 
some thought should be exercised as to the future. Consequently, the 
operation will be resorted to more frequently in multiparae. If this 
is not done, tentative attempts at delivery with forceps should be made, 
and if these fail craniotomy should be performed. Not a few authorities 
advise pubiotomy or extraperitoneal cesarean section under these condi¬ 
tions, but in my opinion the results obtained are by no means com¬ 
mensurate with the added risk to which the patient is subjected. 


TREATMENT OF LABOR IN CONTRACTED PELVIS 


867 


If the line of treatment which we have outlined for hospital practice 
be rigorously carried out, the foetal mortality will hardly exceed that 
occurring in normal labor, while the maternal mortality will be reduced 
to a minimum. On the other hand, when the forceps is employed 
tentatively and is followed by craniotomy in unsuccessful cases, the foetal 
mortality will approach 50 per cent., but the danger to the mother will 
be only slightly increased. 

Breech and Face Presentations in Contracted Pelves. —The existence 
of a breech presentation in moderate degrees of pelvic deformity should 
be regarded as a complication especially unfavorable for the child, in¬ 
asmuch as in the early stages of labor prolapse of the cord is facilitated, 
and in the later stages serious delay may be encountered in the ex¬ 
traction of the after-coming head, which is almost uniformly followed 
by the loss of the child. Moreover, as the head is not in contact with 
the superior strait, it is difficult to determine the degree of disproportion. 
For these reasons, one is justified in being somewhat more liberal in 
the indications for cesarean section if the diagnosis is made early. On 
the other hand, if the patient is not seen until late in labor, and pre¬ 
sents any considerable disproportion, it is advisable to lay the Gigli 
saw prophylactically before attempting extraction. If the head passes 
the superior strait without difficulty, all is well; but, if not, the pubis 
should be sawed through, after which delivery can be readily effected. In 
my hands, this procedure has proved most satisfactory, and has given 
me a sense of security which was previously woefully lacking. So far 
as the mother is concerned, breech presentations are rather favorable, 
for the soft breech does not subject her soft parts to such injurious 
pressure as the hard head; and if delivery becomes imperative, ex¬ 
traction can usually be accomplished without great difficulty, unless the 

pelvic contraction is very marked. 

In frank breech presentations, when the pelvis is but slightly con¬ 
tracted and there is reason to believe that interference will become 
necessary, it is advisable, as a prophylactic measuie, to bring down one 
foot soon after rupture of the membranes, so that extraction can be 
effected promptly when indicated. 

Face and brow presentations should be regarded as much more serious 
complications, as their existence usually indicates a marked degree of 
disproportion and an increased probability of the necessity for operative 
interference. If the pelvic contraction is at all serious, too much should 
not be expected from Nature, and radical measures should be promptly 
employed. On the other hand, when one feels fairly satisfied that the 
disproportion is not excessive and can be overcome, an attempt should 
be made to convert the presentation into a vertex by one of the recog¬ 


nized procedures. . , 

Use of Forceps in Contracted Pelves. —Generally speaking, the em¬ 
ployment of high forceps is contra-indicated in contracted pelves, espe¬ 
cially when the head is freely movable above the superior strait ; as the 
failure to engage after several hours of efficient second-stage pains mdi- 
cMes that the disproportion is too great to be overcome. In such cases 
forcible attempts to drag the head through the pelvis will lead to fatal 






868 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


injury of the child, and frequently to the death or to serious lesions 
on the part of the mother. Too many cases in hospital and consultation 
practice abundantly bear out the truth of this assertion. On the other 
hand, after the head has become well molded and is fixed at the pelvic 
brim, the tentative application of forceps is justifiable. If, however, 
a few tractions are not followed by descent, the obstetrician must be 
prepared to resort to craniotomy, rather than to a major operation. 

When the greatest circumference of the head has passed the superior 
strait, the employment of forceps is governed by the same rules as in 
normal pelves, for in such cases the operation is not performed on 
account of the contracted pelvis, but for one of the usual indications. 

Version in Contracted Pelves.—Version is frequently recommended 
as a satisfactory method of delivery in contracted pelves, and many 
authorities compare its advantages with those obtained with the forceps. 

Sir James Y. Simpson pointed out that the after-coming head offered 
more favorable conditions than the vertex for passing through a con¬ 
tracted pelvis, as smaller diameters are the first to encounter and over¬ 
come the resistance offered by the superior strait. But although version 
undoubtedly presents some advantages so far as the mother is concerned, 
these are more than counterbalanced by the dangers to which it exposes 
the child. Thus Lichtenstein stated that the foetal mortality in 154 
operations performed in Leopold’s clinic from 1901 to 1905 was 26.62 
per cent. Moreover, the advantages of version are markedly diminished 
by the fact that it must be performed soon after rupture of the mem¬ 
branes if satisfactory maternal results are to be obtained. This limits 
considerably its range of usefulness, as one is compelled to operate 
before the uterine contractions have had an opportunity to exert their 
full effect in molding the head; consequently it will be impossible to 
subject the patient to the test of labor, so that many cases will be 
delivered artificially, which, if let alone, would have terminated spon¬ 
taneously. 

Formerly many of the German authorities recommended the per¬ 
formance of so-called 'prophylactic version —turning at the onset of the 
second stage—in all cases of moderate disproportion. This practice does 
not appear justifiable for several reasons. In the first place, it does 
away with the possibility of the test of labor and converts all into 
operative cases; and, on the other hand, when the operation is per¬ 
formed at the most favorable time, just after the rupture of the mem¬ 
branes, the head has had no chance of becoming molded, and accordingly 
must be dragged through the pelvis with only such diminution in size 
as results from a few minutes’ traction. Moreover, a mistake in the 
estimation of the degree of disproportion always results in foetal death; 
since if any serious obstacle to extraction is experienced, only a few 
minutes can elapse between the birth of the umbilicus and the delivery 
of the head, and in this event sufficient time is not available to permit 
of any other operation being performed in the hope of saving the child. 

Induction of Premature Labor.—In the past, in moderate degrees of 
pelvic deformity many authorities recommended the induction of pre- 
mature labor at the thirty-fourth or thirty-sixth week of pregnancy, and 


TREATMENT OF LABOR IN CONTRACTED PELVIS 


869 


some still do so in the hope that the smaller and softer head will be 
born more readily than at term. This is undoubtedly the case, and the 
operation, if properly performed, should have a maternal mortality of 
less than 1 per cent. Personally, I have never induced labor for this 
indication and do not recommend it. It is applicable only to the more 
moderate degrees of contraction, in which spontaneous labor at term 
is the rule; while the children frequently succumb to the operation, 
or, when born alive, are so imperfectly developed that even with the 
most careful attention hardly more than 50 per cent, survive the first 
year. 

Sarwey, in 1906, collected 2,200 cases from 50 operators, and found 
that 484 of the children were born dead, and that an additional 343 
of those born alive succumbed before leaving the hospital—a net mortality 
of 37.3 per cent. Voorhees reported, in 1905, a primary mortality of 
21 per cent, from CragiiTs clinic, and Norris one of 13 per cent. These 
results, to my mind, are not so good as those following the expectant 
treatment at full term, and are far inferior to those following the more 
general performance of cesarean section or pubiotomy in the class of 
cases under discussion. Indeed, the foetal mortality, direct and indirect, 
attending the induction of premature labor is so great that it can 
scarcely be regarded as a means of saving foetal life. 

My own experience fully confirms the conclusions of Baisch con¬ 
cerning the great value of expectant treatment in contracted pelves. In 
his exhaustive study he clearly lemonstrated that the results for the 
child improve as the use of high forceps, prophylactic version, and the 
induction of labor is restricted, while at the same time the maternal 
mortality is not increased. This was also shown by studying the course 
of labor in 701 cases of contracted pelvis occurring in a series of 4,500 
patients in our service. In the first 2,000, high forceps and version 
were frequently employed, while in the last 2,500 patients labor was 
conducted in a much more expectant manner, but cesarean section or 
pubiotomy was freely employed whenever radical interference was indi¬ 
cated, with the result that the total operative frequency fell from 32 
to 21 per cent., while the gross and net foetal mortality fell from 
11.3 to 8.3 per cent, and from 4.73 to 3.38 per cent., respectively. At 
the same time the maternal mortality was reduced nearly one half. 

Accordingly, it appears that intelligent expectant treatment, while 
reducing the total number of operations, necessitates the more frequent 
employment of radical procedures, but at the same time definitely re¬ 
duces both foetal and maternal mortality. It should always be remem¬ 
bered that a spontaneous outcome may be expected in from 75 to 80 
per cent, of all contracted pelves, and that radical surgical interference 
will be necessary in less than one half of the operative cases, and to a 
still lesser extent in the class of cases in which the induction of labor 

is advocated. . _ , 

To my mind, the claims of the advocates of the induction of pre- 

mature labor may be disposed of by a reductw ad absurdum— namely, 
that better foetal results could be obtained by allowing all patients 
in whom it appears indicated to go to full term and perfoiming crani- 




870 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


otomy whenever spontaneous labor does not occur. For this reason it 
seems to me, whenever the induction of premature labor is frequently 
employed, that it must in many instances have been resorted to un¬ 
necessarily. 

On the other hand, in patients presenting moderate degrees of pelvic 
contraction without serious disproportion, labor should be induced as 
soon as the calculated end of pregnancy has been reached, as it seems 
irrational to stand idly by and to watch the child increase beyond the 
usual limits of size. In such cases, labor should be induced by Watson’s 
method, or, if it fails, by the introduction of a bougie. This, however, 
is not the induction of premature labor, but rather the termination of 
pregnancy after the child has attained full maturity. 

In conclusion, it cannot be too forcibly impressed upon the student 
that the repeated delivery of dead children in cases of contracted pelves 
is unjustifiable. The loss of a child may frequently be perfectly ex¬ 
cusable in a single labor, but its repeated occurrence indicates a neglect 
of human life which should not be tolerated, and physicians should 
learn that it is their duty, if they do not feel competent to cope suc¬ 
cessfully with such cases, to send them to a well-regulated hospital or 
to confide them to the care of a competent specialist for treatment. 


TREATMENT OF LABOR COMPLICATED BY OSTEOMALACIC 

PELVES 

The course of labor in osteomalacic pelves varies according to the 
stage of the disease and the degree of contraction. When the deformity 
is slight its influence upon the labor is minimal, but when marked it 
frequently gives an absolute indication for cesarean section. 

Some idea of the obstacle offered to labor by this class of pelves may 
be gained from the figures of Litzmann, which were collected in 1861, at 
a time when the mortality attending cesarean section was so appalling 
that the operation was undertaken only under the most pressing indica¬ 
tions. He tabulated 79 cases from the literature, and found that the 
following operations had been performed: 40 cesarean sections, 16 per¬ 
forations, 1 symphyseotomy, 2 inductions of premature labor; while 7 
women had succumbed to rupture of the uterus, and 4 others had died 
undelivered. 

Latzo, in 1897, considered the effect of osteomalacia upon the course 
of labor in 85 patients who came under his observation. These women 
had gone through 290 labors before, and 169 after, the appearance of 
the disease. In the first group operative interference was necessary 
once in every 48 cases, and in the second once in every 4.9 cases—in 
other words, labor had become ten times more difficult. 

If the patient is seen during the early months of pregnancy and is 
suffering from the disease in its acute stage, she should be at once 
removed to a hospital where she can live under the best hygienic sur¬ 
roundings and be supplied with an abundance of suitable food. Phos¬ 
phorus or adrenalin should be administered tentatively. Latzo, Winckel, 


LITERATURE 


871 


and others state that the former in doses of 2.4 to 4 milligrams per 
day frequently leads to a permanent cure; while Bossi and others make 
similar claims for the curative properties of the latter, which is ad¬ 
ministered in large doses of 0.3 to 0.5 c.cm. of a 1 to 100 solution. 
Benzel and others claim that the use of the X-ray is sometimes followed 
by surprising results. 

If tentative treatment is not satisfactory, or the patient is not seen 
until the end of pregnancy or the time of labor, the treatment to be 
pursued depends altogether upon the degree of pelvic contraction. In 
such cases attention should be paid not only to the length of the 
conjugata vera, but more particularly to the dimensions of the inferior 
strait. In florid cases the bones may be so soft as to resemble leather in 
consistency, and the pelvis readily assumes various forms. This affords 
an explanation of the fact that one is occasionally surprised to see 
delivery accomplished through a pelvis which at first glance appears to 
offer no possibility of such an occurrence. Quite a number of such cases 
are recorded in the older literature, but such an outcome should be 
regarded as very exceptional, and should not lead us to expect too much 
of Xature. 

If the pelvis is markedly contracted cesarean section should be per¬ 
formed without hesitation, followed by the removal of the uterus and 
ovaries, or by castration alone. Fehling has shown that either of these 
operations leads to the permanent cure of the disease in about 80 per 
cent, of the cases, and Seitz in 1913 collected 328 cases with 87 per 
cent, of cures. If, however, delivery occurs spontaneously, or has been 
effected by forceps or version, castration should be performed soon after 
the puerperium in the hope of checking the disease. 

LITERATURE 

Ahlfeld. Ueber die Zerreissung der Schamfuge wahrend der Geburt. D. I., 
Leipzig, 1868. 

Bestimmungen der Grosse und des Alters der Erucht vox der Geburt. Aicliiv I. 
Gyn., 1871, ii, 353-372. 

Baisch. Reformen in der Therapie des engen Becken. Leipzig, 1907. 

Bar. Lemons de pathologie obstetricale. Paris, 1900. 

Benzel. Die Behandlung der Osteomalazie an der Strassburger Erauenklinik. 
Archiv f. Gyn., 1917, cvii, 268-282. 

Braun von Fernwald. Ueber Sympliysenlockerung und bymphysenruptur. 
Archiv f. Gyn., 1894, xlvii, 104-129. 

Breisky. Extramediane Einstellung des Kindeskopfes, etc. Archiv f. Gyn., 1870, 
i, 173-174. 

Burger. Die Geburtsleitung bei engen Becken. W ien, 1908. 

De Lee. Two Cases of Rupture of the Symphysis Pubis during Labor. Amer. 

Jour. Obst., 1893, xxxviii, 483-499; also 1901, xliii, 630-633. 

Fehling. Ueber Wesen und Behandlung der puerperalen Osteomalacie. Archiv 

f. Gyn., 1891, xxxix, 171-196. 

Weitere Beitrage zur Lehre von der Osteomalacic. Archiv f. Gyn., 1895, xlvm, 
472-498. 

Glaser. Ueber spontane Gcburtcn bei engen Becken. D. I., Munchen, 1898. 






872 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 


Kehrer. Sympliysenlockerung und Symphysenruptur. Monatsschr. f. Gcb. u. 
Gyn., 1915, xlii, 321-372. 

Kerr. Diagnosis and Treatment of Contracted Pelves. Trans. Am. Gyn. Soc., 
1911, xxxvi. 

Kronig. Die Therapie bei engen Becken. Leipzig, 1901. 

La Torre. Le developpement du foetus chez les femmes a bassin vicie. Paris, 
1887. 

Latzo. Beitriige zur Diagnose und Therapie der Osteomalacie. Monatsschr. f. 
Geb. u. Gyn., 1897, vi, 571-608. 

Lichtenstein. Ueber die BeeinHussung der Indication zur Wendung u. Extrac¬ 
tion durch die Hebotomie. Archiv f. Gyn., 1907, lxxxi, 626-647. 

Litzmann. Die formen des Beckens, nebst einem Anhange liber die Osteomalacie. 
Berlin, 1861. 

Ueber die hintere Scheitelbeineinstellung. Archiv f. Gyn., 1871, ii, 433-440. 

Die Geburt bei engem Becken. Leipzig, 1884. 

Ludwig und Savor. Klin. Bericht iiber die Geburten beini engen Becken, Bericht 
aus der II. gcb-gyn. Klinik in Wien. Wien, 1897, 120-353. 

McDonald. Mensuration of the Child in the Uterus with New Methods. J. Am. 
Med. Ass., 1906, xliii, 1979-1983. 

Menge. Zur Therapie des engen Beckens. Monatsschr. f. Geb. u. Gvn., 1910, 
xxxi, 687-701. 

Miciiaelis. Das enge Becken. Leipzig, 1851. 

Muller. Ueber die Prognose der Geburt bei engem Becken. Archiv f. Gyn., 
1896, xxvii, 311. 

Norris. Intrapelvic versus Abdominal Method of Dealing with Mechanical Ob¬ 
struction to Delivery. Trans. Am. Gyn. Soc., 1908, xxxiii, 182-212. 

Peham. Das enge Becken. Wien, 1908. 

Perret. La cephalometrie externe, etc. L ’obstetrique, 1899, iv, 542-584. 

Pinard. Du palper mensurateur. Traite du palper abdominal, 2me ed., Paris, 
1889, 202-222. 

Note pour servir a Uhistoire de la puerieulture pendant la grossesse. Annales 
de gyn. et d’obst., 1898, 1, 80-89. 

Riggs. A Comparative Study of White and Negro Pelves. Johns Hopkins Hos¬ 
pital Reports, 1904, xii, 422-454. 

Sarwey. Resultate der wegen Beckenenge vorgenommenen kiinstlichen Friihge- 
burten, etc. Wmckel’s Handbuch d. Geburtshilfe, 1906, iii, 142-147. 

Schauta. Allg. Pathologie der Beckenanomalien. Muller’s Handbuch der Geb., 
1889, ii, 265-284. 

Die Castration bei Osteomalacie. Wiener med. Wochensclir., 1900. 

Schwartz. Ueber die Haufigkeit des engen Beckens. Monatsschr. f. Geburtsh., 
1865, xxvi, 437-442. 

Seitz. Die Osteomalacie in ihren Beziehungen zur inneren Sekretion und zur 
Schwangersehaft. Innere Sekretion und Schwangerschaft. Leipzig, 1913. 

Sellheim. Ueber Geburtsvorgang und Geburtsleitung beim engen Becken. Volk- 
mann’s Samml. klin. Yortrage, 1912, Nr. 649. 

Simpson. Memoir on Turning, as an Alternative for Craniotomy and High 
Forceps, etc., 1850. 

Selected Obstetrical and Gynaecological Works. Edinburgh, 1871, i, 393. 

Tarnier et Budin. Traite de 1’art des accouchements. 1898, t. iii, 70-135. 

Valency. De l’accouchement spontane dans les bassins retrecis rachitiques. 
These de Paris, 1900. 

Varnier. Accommodation de la tete foetale au bassin maternal. L ’obstetrique 
journaliere, Paris, 1900, 131-149. 

Voorhees. A Report of Seven Caesarean Sections. Am. J. Obst., 1905, Iii, 161-190. 


LITERATURE 


873 


Wilcke. Das Gebnrtsgewicht der Kinder bei engem Beeken. Beit,rage zur Geb. 
u. Gyn., 1901, iv, 291-302. 

Williams. The Abuse of Cesarean Section. Surg. Gvn. and Obst., 1917. 

A Critical Analysis of Twenty-one Years’ Experience with Cesarean Section. 
Bull. Johns Hopkins Hosp., 1921, xxxii, 173-184. 

Winckel. Behandlung der Osteomalacie. Penzoldt u. Stintzing’s Handbuch der 
spec. Therapie, v. Abth., 1896, vii, 214-242 (full literature). 

Ueber die Erfolge der Kast,ration bei der Osteomalacie. Volkmann’s Sammlung 
klin. Yortrage, N. F., Nr. 28. 

Zangemeister. Beitrag zur Lehre vom engen Beeken. Zentralbl. f. Gyn., 1922, 
1395-1406. 





CHAPTER XXXVII 

PELVIC ANOMALIES DUE TO DISEASE OF THE VERTEBRAL COLUMN 

KYPHOTIC PELVIS 

History.—Kyphosis or humpback, the result of spinal caries, plays 
an important part in the production of pelvic abnormalities, for when 
situated in the lower portion of the vertebral column it is usually asso¬ 
ciated with a characteristically funnel-shaped pelvis. 



Fig. 622.—Longitudinal Section through Pelvis and Spinal Column in Dorso- 

lumbar Kyphosis (Breus and Kolisko). 


We are indebted to Rokitansky for the first accurate work upon the 
subject, although as early as 1759 Madame Boursier de Coudray reported 
a cesarean section performed upon a patient having a pelvis of this 
character. 

The most important contribution to our knowledge concerning the 
kyphotic changes was made by Breisky (1865), who clearly set forth the 
mechanical factors by which the alteration in shape was brought about. 

874 














KYPHOTIC PELVIS 


875 


Later,^ Chantreuil, Champneys, Barbour, Treub, and particularly Breus 
and Ivolisko added materially to our knowledge of the subject. 

the effect exerted upon the pelvis by kyphosis differs according to 
its location. When the gibbus or hump is situated in the dorsal region, 
it is usually compensated for by marked lordosis beneath it, so that the 
pelvis itself is but little changed. On the other hand, when situated at 
the junction ol flie dorsal and lumbar portions of tbe vertebral column 
its effect upon tlie pelvis becomes manifest, and is still further accentu- 



Fig. 623. —Kyphotic Pelvis Showing Elongation of Conjugata Vera. 


ated when the kyphosis is lower down, being most marked when it is 
at the lumbosacral junction. 

Klien analyzed 85 cases reported in the literature, and found that the 
kyphosis was dorsolumbar in 24, lumbar in 17, and lumbosacral in 37 
cases, while in 7 other cases the vertebral column so overhung the 
superior strait as to produce a “pelvis obtecta '” (Fig. 624). 

Characteristics.—The characteristic feature of the kyphotic pelvis is 
a retropulsion and rotation of the sacrum, by which the promontory 
becomes displaced backward and the tip forward. At the same time 
the entire bone becomes elongated vertically, and narrowed from side to 
side. These changes are associated with a rotation of each innominate 
bone about an axis, which extends through the symphysis pubis and the 
sacro-iliac articulation, so that the iliac fossae becomes flared outward 
while the lower portions of the ischial bones are turned in toward the 
middle line. 

When the kyphosis is in the dorsolumbar region, marked lordosis 
below it indicates an attempt at compensation, but as this is imperfect 



the body weight is transmitted to the sacrum in such a manner that the 
latter becomes retroposed and lengthened, its promontory being farther 
backward and at a higher level than usual. At the same time its an¬ 
terior surface loses its normal vertical concavity and becomes straight 
or even convex; while its lateral concavity is obliterated by the projection 
of the vertebral bodies beyond their alae. The bodies themselves are 
considerably narrower than usual, and the alae of the first sacral vertebra 
appear to be drawn out and to extend obliquely upward to the prom¬ 
ontory. 

Owing to its backward displacement the posterior surface of the 
sacrum approaches the superior posterior spines of the ilium, thereby 
relaxing the iliosacral ligaments. At the same time the posterior ex¬ 
tremities of the innominate bones are pushed apart, and as a consequence 
their upper portions rotate outward and the lower portions inward, so 


that the crests are 
flared out and occupy 
a lower level than 
usual, while the ischial 
spines and tuberosities 
approach the middle 
line. This movement 
of rotation is still 
further accentuated by 
the increased tension 
exerted by the ilio¬ 
femoral ligaments re¬ 
sulting from a diminu¬ 
tion of the pelvic 
inclination. The ace- 
tabula also are shifted 



Fig. 624.— Pelvis Obtecta (Fehling). 


slightly and look more to the front than usual. Coincident with the 
displacement of the sacrum, the iliopectineal line becomes longer, par¬ 
ticularly in its iliac portion. 

These changes give rise to a funnel-shaped pelvis, in which, as the 
11 suit of the increase in the length of the conjugata vera, the superior 
st ait becomes lound 01 o\al in shape, with the long diameter running 
anteroposteriorly, while the transverse diameter remains unchanged or 
ma\ c\cn be somewhat shorter than usual. There is also a gradual 
diminution of all the anteroposterior diameters of the pelvis below the 
supeiioi sti ait, but the most characteristic change is the shortening of 
the distance between the ischial spines, and to a somewhat less extent 
oi that between the ischial tuberosities. The pelvic inclination is usually 
decreased, though in some cases it is only slightly altered. 

Tn 18 kyphotic pelves described by Breus and Kolisko the conjugata 
vera varied from 10.7 to 16.5 centimeters in length, the distance between 
the spines from 5.2 to 8.2 centimeters, and that between the ischial 
tuberosities from 6 to 12.1 centimeters. At the same time it should 
be remembered that in not a few cases the entire cavity is smaller than 
usual, Klien having pointed out that 30 per cent, of all kyphotic pelves 





KYPHOTIC PELVIS 


877 


which he studied were also generally contracted, so that a conjugata vera 
which at first glance appears normal may in reality be relatively in¬ 
creased in length. 

When the kyphosis is situated at the junction between the last lumbar 
and the first sacral vertebrae, the pelvic changes are more marked than 
those just described, as the promontory of the sacrum is usually carious 
and takes part in the formation of the gibbus. In such cases there 
can be no attempt at compensation, as the body weight is transmitted 
directly to the anterior surface of the sacrum, so that its upper part 
is pushed far backward. It is not lengthened, and its alae are usually 
very small. In such cases the transverse contraction becomes still more 
marked, so that the distance between the ischial spines may be reduced 
to 3 or 4 centimeters, as in the cases described by Schroeder and Doktor. 
The pelvic inclination is always diminished, and in some cases is entirely 
obliterated. 

When the kyphosis is very marked, the lumbar vertebrae may so 
overhang the superior strait as effectively to prevent the child’s head 
from entering it. This condition was described by Fehling as pelvis 
obtecta. In his specimen the distance between the symphysis pubis and 
the nearest point on the vertebral column was 3.8 centimeters. A 
similar condition was noted in 8 per cent, of the cases analyzed by Klien, 
and has been described by Herrgott as spondylizeme. 

Mode of Production.—A kyphosis in the dorsal region is usually com¬ 
pensated for by a marked lordosis below it, so that the body weight is 
transmitted to the sacrum in the usual manner. On the other hand, as 
Breisky pointed out, when the hump is situated lower down, the body 
weight is transmitted through its upper limb, and on reaching the 
gibbus becomes resolved into two components, one of which is directed 
downward and the other backward. This latter force draws the prom¬ 
ontory of the sacrum backward and upward, thus leading to rotation and 
elongation of the entire bone (Fig. 625). 

Breus and Kolisko have shown that, owing to the necrosis of one or 
more of the vertebral bodies forming the gibbus, the body weight is not 
transmitted directly through the vertebral bodies below it, but through 
their arches and spinous processes. As a result the latter come into 
close contact, while the interior portions of the vertebrae become widely 
separated, thus leading to marked lordosis beneath the gibbus. This 
causes an upward drag upon the bodies of the sacral vertebrae, which 
become sfretched and elongated. Coincident with these changes, and 
resulting from the backward displacement of the sacrum, as well as 
from the increased tension exerted by the iliofemoral ligaments, the 
innominate bones likewise undergo rotation, which brings about a nar¬ 
rowing of the lower portions of the pel\ is. 

Frequency— According to Klien’s statistical study a kyphotic pelvis 
is met with once in every 6,016 labors, although he himself believes 
that this estimate is too low, in view of the fact that humpbacked 
women are relatively numerous. On the whole, it is probable that any 
one who has an extensive obstetric practice is liable to meet with this 

abnormality. 



878 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 

Diagnosis.—The diagnosis is usually easy, as the external deformity 
is readily detected and should at once suggest the possible existence of 
a funnel pelvis. 

External pelvimetry is of great value, as it shows that the distance 
between the iliac crests is equal to or exceeds that between the tro¬ 
chanters, whereas normally the reverse is true. In a patient suffering 


Fig. 625.—Diagram Showing Forces Concerned in the Production of Kyphotic 

Pelvis (Tarnier). 

from this deformity, lines drawn through the iliac crests and trochanters 
will meet somewhere in the neighborhood of the feet, instead of near the 
head as is generally the case. 

On palpation of the pubic arch the transverse narrowing of the 
pelvic outlet will be noted, while internal examination will reveal the 
lengthening of the conjugata vera. In lumbosacral kyphosis the prom¬ 
ontory no longer exists, and the bodies of the lower lumbar vertebra 











KYPHOTIC PELVIS 


879 


overhang the superior strait. Accordingly, in this variety of pelvis 
particular attention should be devoted to estimating the length of the 
“pseudoconjugate’'--the distance from the upper margin of the symphysis 
pubis to the nearest portion of the vertebral column. Occasionally the 
condition may be confounded with spondylolisthesis, and the differential 
diagnosis will be considered under the latter heading. 

Effect upon Labor.—Owing to the collapse of the vertebral column, 
the ribs approach the pelvic brim and thereby lessen the capacity of the 





Fig 6 9 6 — Patient with Obliquely Contracted, Kyphotic, Funnel Pelvis. In 
' A note that body weight is borne by right leg. In B note presence of double gibbus. 
The lumbo-sacral one is concerned in producing the funnel pelvis. 


abdomen, which in consequence becomes markedly pendulous at an early 
period of pregnancy. These mechanical conditions fatoi the occunence 
of abnormal positions of the foetus, and Klien, in 103 cases, found 100 
longitudinal and 3 oblique presentations. Of the former 90 were vertex, 

4 face, and 6 breech presentations. 

It is interesting to note that left occipito-anterior presentations occur 
much less frequently than usual, being noted in only one-third of the 
cases while the remainder are equally divided between right anterior 
and posterior presentations. It is difficult to give a satisfactory explana¬ 
tion for the unusual frequency of the right anterior position, but the 













SSO PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 


production of posterior positions is due to the pendulous abdomen, as 
in sucli circumstances the concave ventral surface of the child tends to 
apply itself to the convex inner surface of the anterior wall of the uterus. 

Except in cases of pelvis obtecta, the presenting part experiences 
no difficulty in entering the superior strait at the time of labor, and no 
obstacle is met with until it reaches the neighborhood of the ischial 
spines. If the transverse contraction be not too marked to prevent the 
descent of the head, further difficulty is encountered when the latter 
attempts to pass beneath the pubic arch, which, owing to the approach 
of the tubera ischii, has become more angular than usual, so that the 
head is prevented from coming in contact with the lower margin of 
the symphysis pubis and must descend lower than usual in order to be 
born. This fact readily explains the deep perineal tears so frequently 
observed. 

Generally speaking, it may be said that when the distance between 
the tubera ischii is less than 8 centimeters labor becomes difficult or 
impossible, according to. the degree of transverse contraction of the 
outlet. In such cases the dystocia is more pronounced than in typical 
funnel pelves presenting identical measurements, for the reason that the 
anterior displacement of the tip of the sacrum is inevitably associated 
with shortening of the posterior sagittal diameter. Owing to the 
narrowing of the pubic arch, occipito-anterior are less favorable 
than occipitoposterior presentations, as in the former the wide biparietal 
diameter has to accommodate itself to the pubic arch, whereas in the 
latter its place is taken by the smaller brow. According to Klien, face 
presentations are still more favorable for the same reason. 

Prognosis.—If the contraction is pronounced, the prognosis is bad 
unless cesarean section is resorted to. Klien has analyzed the histories 
of 175 labors occurring in 95 women, and found that 40 per cent, of 
the children died. The maternal mortality varied according to the 
degree of contraction; when the disproportion between the biparietal 
diameter of the child’s head and the distance between the spines was 
slight, it was 6.2 per cent., as compared with 17 per cent, in marked 
cases. „ 

Neugebauer has likewise analyzed the histories of 199 labors occur¬ 
ring in 118 women, and found that only 44 ended spontaneously. The 
maternal mortality was 24.3 per cent., and 49 per cent, of the children 
died. 

Treatment.—\\ hen the distances between the spines and tuberosities 
oi the ischium do not fall below 8 centimeters, spontaneous labor, or at 
least a probable delivery with low or mid forceps, can he looked for, pro¬ 
vided the posterior sagittal diameter is not too shortened; but when 
the measurements are below this limit operative interference becomes 
necessary. Unless the child is very small, cesarean section is usually the 
operation of choice. Pubiotomy, however, may be considered if the dis¬ 
tance between the spines or tubera does not fall below 6 centimeters, as it 
v ill peimit the passage of the head, and may lead to a permanent 
increase in the dimensions of the pelvic outlet. ' If the child is already 
dead, craniotomy is the operation of election. 


SCOLIOTIC PELVIS 


881 


KYPHORHACHITIC PELVIS 

Kyphosis is nearly always of carious origin, but when due to rhachitis 
it is usually associated with a greater or lesser degree of scoliosis. In the 
rare cases of pure rhachitic kyphosis, however, the pelvic changes are 
slight, as the effect of the kyphosis is counterbalanced to a great extent 
by that of the rhachitis, the former leading to an elongation and the 
latter to a shortening of the conjugata vera, while tending, respectively, 
to narrow and to widen the inferior strait. Thus it may happen that a 
woman presenting a markedly deformed vertebral column of this char¬ 
acter may still have a practically normal pelvis. The two processes, 
however, do not always counteract one another, and, as a rule, when 
the kyphosis is high up the pelvic changes are predominantly rhachitic. 


SCOLIOTIC PELVIS 

Pronounced scoliosis, or lateral curvature of the spine, is usually of 
rhachitic origin* but, on the other hand, minor degrees of the deformity 



Figs. 


Fig. 627. 

627-628 —Obliquely Contracted Non-rhachitio Scoliotic 

and Kolisko). 


Fig. 628. 
Pelvis (Breus 


are often observed which have no connection with rickets. When the 
scoliosis involves the upper portion of the vertebral column, it is usually 
compensated for by a corresponding curvature in the opposite direction 








882 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 

lower down, thus giving rise to a double or S-shaped curve. In such 
cases the body weight is transmitted to the sacrum in the usual manner. 
But when the scoliosis is lower down and involves the lumbar region, the 
sacrum takes part in the compensatory process and accordingly assumes 
an abnormal position which leads to slight asymmetry of the pelvis. 

Breus and Kolisko ha\ r e devoted particular attention to the pelvic 
anomalies resulting from non-rhachitic scoliosis, but the changes in 
shape are usually so slight as to have little or no effect upon the course 
of labor. 



Fig. 629. Fig. 630. 

Figs. 629-630. —Scoliorhachitic Pelvis (Tarnier). 


When due to rhachitis, the scoliosis may be very pronounced, and 
give rise to marked pelvic deformity, in which the characteristic changes 
due to the anomaly of the vertebral column are superadded to those 
resulting from rhachitis. In such cases the scoliotic convexity is usually 
directed to the right side, as was noted in 7 out of the 9 cases described 
by Leopold. 

In such circumstances the sacrum takes part in the compensatory 
scoliosis, one side being compressed and the other elongated, so that 
its long axis becomes directed obliquely toward one side. At the same 
time it undergoes a partial rotation about its vertical axis, the spinous 
processes being directed toward the compressed side, a result which indi¬ 
cates the abnormal direction along which the body weight is transmitted 
to the iliac bones, and thence to the femurs. Owing to the abnormal 
pressure exerted upon one side, the pelvis becomes obliquely contracted, 
usually upon the side corresponding to the lumbar convexity; but, owing 



KYPHOSCOLIOTIC PELVIS 


883 


to the coexistence of rhachitic changes, the contraction is in great part 
limited to the superior strait. 



Owing to the pressure exerted upon the compressed side of the sa- 
cium, ankylosis at the sacro-iliac articulation often occurs. At the same 
time the innominate bone on the affected side is displaced upward, in- 
waid, and backward, while its acetabulum looks more forward than 
usual. The symphysis pubis is brought somewhat nearer to the opposite 
side, and owing to the rhachitic changes the pubic arch is widened, 
while the tubera ischii are directed outward instead of inward as in 
the Naegele pelvis. In pronounced cases the superior strait assumes an 


Fig. 631. Fig. 632. 

Figs. 631-632. —Kyphoscoliotichrachitic Pelvis (Leopold). 


| obliquely ovate appearance, and occasionally the acetabulum on the 
I affected side may come almost in contact with the promontory. 

The location of the contraction can be determined by external ex¬ 
amination, as it always lies upon the side toward which the convexity 
of the scoliosis is directed. The contracted side is valueless from an 
obstetrical standpoint, and for practical purposes the superior strait be- 
: comes generally narrowed. If, however, the head manages to pass 
through it, no further difficulty is experienced in its downward course, 
owing to the rhachitic widening of the lower portion of the pelvis. 

KYPHOSCOLIOTIC PELVIS 


In this type, the distortion of the pelvis will vary according as the 
kyphosis or the scoliosis is the predominant factor in the deformity of 
the spinal column. When the former is more pronounced the pelvis will 
partake of the kyphotic character, and vice versa. When the two de- 











884 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 


formities are approximately equal, however, the kyphotic changes in the 
pelvis predominate, although the influence of the scoliosis tends to 
counteract, to a certain extent, the transverse narrowing of the inferior 
strait. 

KYPHOSCOLIORHACHITIC PELVIS 



This variety of pelvic 
by Leopold, and Barbour. 


Fig. 633. —Vertical Section through 
Spondylolisthetic Pelvis (Kilian). 

obstetrical standpoint than that due 


has been studied more particularly 
pointed out, a kyphosis 
due to rhachitis is nearly always 
complicated by a scoliosis and the 
latter usually predominates in the 
production of the pelvic de¬ 
formity, for the reason that the 
kyphosis and the rhachitis tend 
mutually to counteract one an¬ 
other in their effect upon the pel¬ 
vis. Accordingly, the resulting 
pelvis does not differ materially 
from that observed in scolio- 
rhachitis, except that the tend¬ 
ency to anteroposterior flattening 
is partially counteracted by the 
action of the kyphotic vertebral 
column. Nevertheless, owing to 
the presence of the scoliosis, the 
oblique deformity of the superior 
strait is usually quite marked. 
Generally speaking, this class of 
pelvis is more favorable from an 
to scoliorhachitis alone. 


deformity 
As has already been 


SPONDYLOLISTHETIC PELVIS 

The term spondylolisthesis (from (nrovSvXos; vertebra, and oXiaO^a^, 
slipping or sliding) was introduced by Kilian in 1853, in describing 
a pelvis in which the last lumbar vertebra had become displaced down-■ 
ward over the anterior surface of the sacrum. 

Characteristics.—The degree of displacement may vary greatly.! 
When the deformity is slight the anterior inferior margin of the Iasi 
lumbar vertebra merely projects a short distance beyond the anterioi 
margin of the promontory of the sacrum; while in pronounced cases the 
entire body of the vertebra is displaced downward and forward into the 
pelvic cavity, so that its inferior surface comes in contact with, ancl 
more or less completely covers, the body of the first, and occasionally 
that of the second sacral vertebra. As a consequence, a greater or lessei 
portion of the lumbar column comes to occupy the upper portion of thf 
pelvic cavity, the superior strait becoming markedly obstructed anc 
assuming a reniform shape. 







SPONDYLOLISTHETIC PELVIS 885 

Ihe lower mmbar vertebrae may overhang the pelvic inlet to such 
an extent that the obstetrical or pseudoconjugate will be represented 
by a line drawn from the upper margin of the symphysis to the lower 
margin of the fourth, third, or even of the second lumbar vertebra, as 
the case may be. Tn the specimen which I described in 1899, it ex¬ 
tended to the lower margin of the third lumbar vertebra and measured 



Fig. 635. Fig. 636. 

Figs. 634-636. —Williams’ Spondyliolisthetic Pelvis. 


6.5 centimeters. The displacement of the 
due not to luxation, but to the 
articular portions. Its inferior articular 
normal relation to the superior articular 


last lumbar vertebra is 

its inter¬ 
processes still retain their 
processes of the first sacral 


lengthening and bending of 


vertebra, whereas its body and its superior articular processes, together 
with the rest of the vertebral column, become displaced forward and 
eventually downward. As a result oi' the new position assumed by 
the body of the last lumbar vertebra, the superior and anterior surfaces 
of the promontory become more or less worn away by friction, the 
defect being frequently followed by ankylosis which definitely checks 










886 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 


further displacement. In advanced cases the inferior articular processes 
of the last lumbar and the superior articular processes of the first sacral 
vertebra are usually firmly synostosed together, as are also the inferior 
articular processes 'of the fourth and the superior articular processes of 


the fifth lumbar vertebra. 

Owing to the collapse of the vertebral column into the pelvic cavity 
the center of gravity falls in front of instead ol just behind the acetab- 
ula, and consequently the pelvis must be tilted backward in order that 
the' individual may retain an upright position. In other words, the 

pelvic inclination must be dimin¬ 


ished, and when the deformity is 
marked the plane of the superior 
strait becomes parallel to, or even 
forms an obtuse angle with, the 
horizon. This is rendered possible 
by changes in the iliofermoral liga¬ 
ments, which are manifested on the 
one hand by a marked roughening 
of the portions of the pelvis to which 
they are attached, and on the other 
by characteristic changes in the gait 
of the patient. In my own case the 
pelvic inclination was obliterated; 
but, had it remained normal, the 
vertebral column would have formed 
a right angle with the legs, necessi¬ 
tating the patient’s going upon all- 
fours, where, as a matter of fact, she 
was able to walk erect. 

As the inferior surface of the 
last lumbar vertebra is in contact 
with the anterior instead of the su¬ 
perior surface of the first sacral 
vertebra, the action of the body 
weight tends to force the promontory of the sacrum backward, thereby 
causing it to rotate about its transverse axis, while its tip approaches 
the lower margin of the symphysis pubis. This rotation, together with 
the increased traction exerted by the iliofemoral ligaments, causes each 
innominate bone to rotate about an axis extending from the symphysis 
to the sacro-iliac joint, and tends to give the pelvis a funnel shape, 
just as in kyphosis, the inferior strait becoming contracted transversely. 

Etiology.—Kilian considered that the displacement of the last lumbar 
vertebra was rendered possible by inflammatory softening of the inter¬ 
vertebral disk. Later, various hypotheses were advanced as to its mode 
of production. Robert, Lambl, and Konigstein showed that the dis¬ 
placement could not take place so long as the inferior articular processes 
of the last lumbar were normal and in contact with the superior articular 
processes of the first sacral vertebra, unless the entire vertebra became 
lengthened. 



Fig. 637.—Spondylolisthesis; Ver¬ 
tical Section through Last 
Three Lumbar Vertebrae and 
Sacrum. XL}. 


t 

I 

1 










SPONDYLOLISTHETIC PELVIS 


887 


Neugebauer devoted thirteen years (1882-95) to the study of this 
subject, and during that period published 15 journal articles and 3 
monographs upon it, covering nearly 900 pages, not to mention the dis¬ 
cussions and demonstrations m which he took part. He showed con¬ 
clusively that in the vast majority of cases the deformity was rendered 
possible by a lengthening and thinning out of the interarticular por¬ 
tions of the last lumbar vertebra, by which its superior and inferior 
articular processes become separated by a long, thin lamina of bone in¬ 
stead of being almost in the same vertical line (Fig. 638). 

This condition he attributed to 
imperfect development of the inter¬ 
articular portion (spondylolysis) or 
to its fracture, with subsequent 
stretching of the callus. He con¬ 
sidered that the former was the more 
frequent causes, as he was able to 
demonstrate it in many vertebrae 
which presented no signs of spondy¬ 
lolisthesis. When the displacement 
is marked the interarticular por¬ 
tion is not only lengthened and 
thinned out, but also becomes bent 
over the promontory of the sacrum, 
thus forming a dolicho-l‘yrto-platy- 
spondylus. 

In opposition to Neugebauer s 
statement that the deformity always 
results from changes in the inter¬ 
articular portion, Chiari definitely 
showed that it can occasionally fol¬ 
low fracture of the articular proc¬ 
esses without the characteristic changes in the vertebra. At the same time, 
he considered that spondylolysis is the usual cause. Goldthwait holds that 
the deformity is usually due to luxation of the inferior articular processes 
of the last lumbar vertebrae over the superior articular processes of the 
sacrum. In this event, the spinal canal would be encroached upon and 
the cauda equina compressed, with resulting paralysis. The absence of 
the latter complication in most pronounced cases of spondylolisthesis 
argues against the correctness of his theory, and in favor of Neuge- 
bauers view, according to which the elongation of the interarticular 
portion of the last lumbar vertebra would lead to an increase in the 
size of the spinal canal, and thus lessen the probability of pressure upon 
the cauda. 

Arbuthnot Lane stated that the disease is more common than is 
generally supposed, as he observed several examples of it in coal-heavers. 
He considers that in such cases, at least, the changes in the interarticular 
portion are due not to abnormalities in development but to excessive 
pressure, which results from carrying heavy burdens. Complete litera- 


A 



Fig. 638.—Fourth and Fifth Lum¬ 
bar Vertebrae from Author’s 
Case of Spondylolisthesis. X H>. 

A, superior articular process; B, trans¬ 
verse process; C, inferior articular 
process; D, lamina of fourth lumbar 
vertebra; E, superior articular 
process; F, inferior articular proc¬ 
ess; G, transverse process; H, 1 , J, 
fissures in interarticular portion of 
last lumbar vertebra. 












888 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 

ture upon the subject will be found in my own article, and in those of 
Breus and Kolisko, and Chiari. 

Frequency.—Neugebauer, in 1893, was able to collect 115 cases of 
spondylolisthesis, most of which were clinical observations. Tn 1899 1 
collected 123 cases, which Chiari, in 1912, increased to 150, including 
17 cases occurring in males—11.3 per cent. According to Breus and 
Kolisko only 20 indisputable anatomical specimens of this condition 
were in existence in 1900, including 2, which they described for the 
first time. 



Effect upon Labor.—When the condition is but slightly marked, its 
effect upon labor is similar to that of a flat pelvis, as the greatest con¬ 
traction is in the conjugata vera, although it should be remembered that 
it is likewise associated with considerable contraction of the inferior 
strait. When the deformity is pronounced and the lower lumbar verte¬ 
brae overhang the superior strait, the degree of contraction, from an 
obstetrical point of view, is to reckoned not by the distance between 
the symphysis pubis and the anterior portion of the last lumbar vertebra, 
but by the length of the pseudoconjugate, whose posterior extremity 
may be at the fourth, third, or even second lumbar vertebra, and in 
many cases is so short as absolutely to preclude the possibility of the 
head entering the pelvis. 

Diagnosis.—In typical cases mere inspection of the patient should 
lead one to suspect the existence of this deformity, inasmuch as there 










SPONDYLOLISTHETIC PELVIS 


S89 



is always marked lumbar lordosis and the entire trunk seems to have 
caved m so that the ribs may come almost in contact with the iliac 
crests \\ hen viewed from the front the abdominal walls appear un¬ 
usually redundant. Such patients have a peculiar ducklike walk or 
waddling gait, to which Neugebauer first directed attention. Since the 
postenor portion of the last lumbar vertebra retains its normal position 
vhile the rest of the vertebral column sinks forward, its spine will some 
times form a marked prominence just 
above the sacrum. The condition, 
however, may lie confounded with a 
deep-seated kyphosis. 

On internal examination the diair- 

. o 

nosis, as a rule, is readily made, as, 
on attempting to measure the diagonal 
conjugata, the body of the last lumbar 
vertebra will be found lying in front 
of the anterior and upper portion of 
the sacrum. At the same time the 
iliopectineal line ends abruptly at the 
margins of the overhanging vertebral 
body, instead of continuing uninter¬ 
ruptedly to the promontory of the 
sacrum. 

Owing to the marked lordosis, 
which frequently accompanies the 
condition, the bodies of the lower 
lumbar vertebrae can readily be pal¬ 
pated and counted, and the bifurca¬ 
tion of the aorta, or at least the com¬ 
mon iliac arteries, are frequently 
readily accessible to the examining 
finger. 

Occasionally pronounced rhachitic 
changes in the sacrum may simu¬ 
late spondylolisthesis, but a correct Fig. 640.—Side View of Author’s 

diagnosis can usually be arrived at. Spondylolisthetic Patient, Show- 
T ° J ing Projecting Spine of Last 

Ill such cases, careful palpation, under Lumbar Vertebra. 

anesthesia if necessary, will show 

that the iliopectineal lines terminate at the promontory of the sacrum 
instead of at the sides of the prolapsed body of the last lumbar vertebra. 

A somewhat similar condition is presented in certain cases of lumbo¬ 
sacral kyphosis, particularly in the pelvis obtecta. Under such circum¬ 
stances the promontory of the sacrum is destroyed, but a correct diag¬ 
nosis can usually be made by carefully palpating the anterior surface of 
the sacrum and tracing the alae to the body of the first vertebra, which, 
of course, is impossible in spondylolisthesis. 

The X-ray is a valuable aid in diagnosis, particularly in slightly 
developed cases. In such circumstances, it may make possible the recog¬ 
nition of a displacement of the last lumbar vertebra too slight to be 







890 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 

detected on vaginal examination, as happened in the case of a patient 

shown me by my assistant, John G. Murray, Jr. 

Prognosis.—Generally speaking, spontaneous labor can occui only 
when the deformity is minimal, and, accordingly, in pronounced cases the 
outlook is uniformly bad for both mother and child unless radical opera¬ 
tive measures be undertaken. Other things being equal, a spondylolis¬ 
thetic pelvis offers a worse prognosis than a rhachitic one with the same 
anteroposterior measurements, for the reason that in the former the 
inferior strait is also contracted, while in the latter it is usually enlarged. 

In considering the probable outcome of labor, one should measure the 
pseudoconjugate with particular care, inasmuch as it, rather than the 
anteroposterior diameter of the superior strait, usually offers the greatest 
obstacle to labor. The fact that a patient with spondylolisthesis has had 
one or more spontaneous labors does not necessarily imply that the labor 
in question will be uneventful, for the reason that the degree of de¬ 
formity frequently increases with age, as happened in my own case. 

Treatment.—With a pseudoconjugate of more than 8 centimeters, the 
possibility of spontaneous labor should be borne in mind; but when it 
falls below that limit cesarean section should be done at an appointed 
time. In slight degrees of contraction, in which spontaneous delivery 
has failed to occur, the propriety of pubiotomy may be considered; but 
in MorisanFs case, as well as in my own, symphyseotomy proved fatal. 


LITERATURE 

Barbour. Spinal Deformity in Relation to Obstetrics. Edinburgh, 1883. 

Boursier de Coudray. Abrege de Dart des accouchements. Paris, 1759. 

Breisky. Ueber den Einfluss der Kyphose auf die Beckengestalt. Zeitschr. der 
Gesellsch. der Aerzte in Wien, i, 1865. 

Breus und Kolisko. Die path. Beckenformen. 1900. Bd. iii, I. Theil, Spondy¬ 
lolisthesis, 17-159. Kyphosen-Becken, 163-307. Skoliosen-Becken, 311-352. 
Kyphoskoliosen-Becken, 355-359. 

Champneys. The Obstetrics of the Kyphotic Pelvis. Trans. Bond. Obst. Soc., 
1883, xxv, 166-194. 

Chantreuil. Etude sur les deformations du bassin chez les cyphotiques. These 
de Paris, 1869. 

Chiari. Die Aetiologie und Genese der sogenannten Spondylolisthesis lumbo- 
sacralis. Zeitschr. f. Heilkunde, 1892. 

Spondylolisthesis. Bull. Johns Hopkins Hospital, 1911', xxii, 41-46. 

Pelikologische Mittheilungen. Verb. d. deutschen path. Gesellschaft, 1912, 
318-337. 

Doktor. Ein Fall von conservativen Kaiserschnitt. Zentralbl. f. Gyn., 1893, 
xvii, 630-633. 

Fehling. Pelvis obtecta. Archiv f. Gyn., 1872, iv, 1-33. 

Goldthwait. The Lumbosacral Articulation, etc. Boston Med. and Surg. Jour., 
1911, clxiv, 365-372. 

Herrgott. Du spondylizeme. Archives de toeologie, 1877 (Fev.-Mars). 

Kilian. De spondylolisthesi gravissimse pelvangustiae causa nuper detecta. Bonn, 
1853. 

Klien. Die Geburt beim kyphotischen Becken. Archiv f. Gyn., 1896, 1, 1-128. 


LITERATURE 


891 


Konigstein. Entstehungsweise spondylolistlietischer Becken. D. I., Marburg, 
1871. 

Lambl. Das Wesen und die Entstehung Spondylolisthesis. Scanzoni’s Bei- 
trage, 1855, iii, 1-77. 

Lane. Some of the Changes Which Are Produced by Pressure in the Lower Part 
of the Spinal Column ; Spondylolisthesis, etc. Trans. Lond. Path. Soc., 1885, 
xxxvi, 364-378. 

Leopold. Das skoliotische und kypho-skol. rachitische Becken. Leipzig, 1879. 

Weitere Untersuchungen iiber das skoliotische und kypho-skol. rachitische 
Becken. Archiv f. Gyn., 1880, xvi, 1-23. 

Morisani. Ancora della Sinfisiotomia. Annali di ost. e gin., 1886, viii, 345-391. 

Neugebauer. Zur Entwickelunsgeschichte des spondylolisthetischen Beckens und 
seiner Diagnose. Halle u. Dorpat, 1882. 

Spondylolisthesis et spondylizeme. Paris, 1892. 

Die heutige Statistik der Geburten bei Beckenverengerung infolge von Riick- 
gratskyphose. Monatsschr. f. Geb. u. Gyn., 1895, 1, 317-347. 

Robert. Eine eigenthiimliche angeborene Lordose, etc. Monatsschr. f. Geburtsk., 
1855, v, 81-94. 

Rokitansky. Anomalien der Gestalt des Riickgrats und seiner Theile. Lehrbuch 
der path. Anat., III. Autl., 1856, ii, 162-172. 

Schroeder-Olshausen-Yeit. Lehrbuch der Geb., XIII. Aufl., 1899, 649. 

Treub. Recherches sur le bassin cyphotique. Leyden, 1889. 

Williams. A Case of Spondylolisthesis, with Description of the Pelvis. Amer. 
Jour. Obst., 1899, xl, 145-171. 

Spontaneous Labor Occurring through an Obliquely Contracted, Kyphotic, Fun¬ 
nel Pelvis. Bull. Johns Hopkins Hosp., 1922, xxxiii, 190-193. 


CHAPTER XXXYIII 


PELVIC ANOMALIES RESULTING FROM THE ABNORMAL DIREC¬ 
TION OF THE FORCE EXERTED BY THE FEMORA—ATYPICAL 
DEFORMITIES 

Normally, in the case of an individual standing erect, the upward 
and inward force exerted by the femora is of equal intensity on either 
side, and is transmitted to the pelvis through the acetabula. In walking 
or running the entire body weight is transmitted alternately first to one 
and then to the other leg. On the other hand, in a person suffering from 
disease affecting one leg, the sound one has to hear more than its share 
of the body weight, and consequently the upward and inward force 
exerted by the femur is, as a rule, greater upon that side of the pelvis. 
To these mechanical factors are due the changes in shape which accom¬ 
pany certain forms of lameness, provided that the lesion, which gives 
rise to the latter, appears at an early period, of life while the pelvic 
bones are still in a formative state. 

The defect may be either unilateral or bilateral; in the former case 
it is usually due to coxitis, luxation of the femur, infantile paralysis, or 
shortening of one leg from various causes, while in the latter case com¬ 
mon causes are luxation of both femora and double club-foot. These 
conditions have been studied in detail by Prouvost, in whose article, as 
well as in the chapters of Tarnier and End in, and of Breus and Kolisko 
upon the subject, full literature is to be found. 


PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS 

Coxalgic Pelvis. — Coxitis occurring in early life nearly always gives 
rise to an obliquely contracted pelvis. If the disease makes its appear¬ 
ance before the patient learns to walk, or if the child is obliged to keep 
to its bed for a prolonged period, the entire organism may suffer from 
imperfect development, which also manifests itself in the pelvis and 
leads to the production of the generally contracted, or justominor type, 
to which are added the mechanical effects and atrophic changes resulting 
from the unilateral disease. These are manifested by imperfect develop¬ 
ment of the diseased side of the pelvis, the innominate bone being 
smaller than its fellow and the iliopectineal line forming the arc of a 
circle having a smaller radius than upon the well side. At the same 
time, the sacral alae are less developed upon the affected side, and the 
entire bone is somewhat rotated about its vertical axis, so that its anterior 
surface looks toward the well side (Fig. 041, A and B). 

892 


PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS 


893 


\\ hen the individual begins to stand, owing to the actual shortening 
ol the diseased leg or to fear of placing it firmly upon the ground, the 




Fig. 641. —Diagram Showing Ooxalogic Pelvis, A, before and, B, after the Individ¬ 
ual Has Walked. 



Fig. 643. Fi g- 644. 

Figs. 642-644. —Coxalgic Pelvis with Ankylosed Femur. 


body weight is transmitted in great part to the well leg. As a result the 
pelvis become obliquely tilted, being higher on the veil side, and a com- 
















894 


PELVIC ANOMALIES—ATYPICAL DEFORMITIES 


pensatory scoliosis appears. At the same time the upward and inward 
force exerted by the femur tends to push the well side of the pelvis up¬ 
ward, inward, and backward, whereby the iliopectineal line is markedly 
flattened and the asymmetry of the sacrum still further increased, thus 
giving rise to an obliquely contracted pelvis. The contraction is not 
limited to the superior strait, but involves the lower portion of the 



Fig. 645. 




Figs. 645-647. —Obliquely Contracted Pelvis, Due to Unilateral Luxation of 

Femur. 


pelvis as well, the spine and tuberosity of the ischium being displaced 
toward the middle line. 

Not uncommonly these changes are accompanied by irritative proc¬ 
esses at the sacro-iliac articulations, which may eventually lead to anky¬ 
losis. As a general rule, the oblique contraction is to be found on the 
well side of the pelvis, but, according to Tarnier, and Briggs, the reverse 
is the case when the affected leg is ankylosed in a position of adduction 
and internal rotation (Fig. 642). 

Oblique contraction of the pelvis may also develop when unilateral 
luxation of the femur occurs in early life, although they are usually 







PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS 895 


less pronounced than those following coxitis. Under such circumstances 
the head of the bone is displaced backward and upward upon the outer 
surface of the ilium, where a new joint surface may occasionally be 
formed. The affected leg becomes considerably shortened, and accord¬ 
ingly an undue share of the body weight is transmitted through the well 
leg, which forces the corresponding side of the pelvis upward, inward, 
and backward, and leads to an oblicpie contraction, just as in coxalgia. 

Unless the patient has had the benefit of proper orthopedic treat¬ 
ment in unilateral infantile 'paralysis, and in those cases in which 
disease at the knee- or ankle-joint or amputation early in life has 
caused shortening of one leg, similar changes occur in the pelvis, though 
it rarely assumes the extreme degree of obliquity which characterizes 
the coxalgic variety. 

Diagnosis. —A limping gait at once suggests an obliquely contracted 
pelvis, and when, upon questioning the patient, it is found that the con¬ 
dition has been present since early childhood, the existence of pelvic de¬ 
formity upon the side corresponding to the sound leg becomes highly 
probable. 

More accurate information can be obtained by careful examination 
and noticing the relative position of the iliac crests and the presence or 
absence of compensatory scoliosis, and finally an absolute diagnosis can 
be arrived at by the employment of the measurements suggested by 
Naegele for the detection of the obliquely contracted pelvis due to im¬ 
perfect development of the sacral alae. An accurate conception con¬ 
cerning the degree of contraction, however, can be obtained only by 
careful exploration of the interior of the pelvis, preferably with the 
patient under the influence of an anesthetic, although in many coxalgic 
patients this may be extremely difficult on account of the ankylosis of 
one leg. X-ray pictures, of course, afford valuable confirmatory infor¬ 
mation. 

Effect upon Labor.— The effect of this type of pelvis upon labor varies 
with the extent and position of the deformity. If the affected side is so 
contracted as to prevent its being occupied by a portion of the piesenting 
part, we have for all practical purposes a generally contracted pel\is, and 
engagement, if it can occur at all, will take place moio leadily when the 
biparietal diameter of the head is in relation with the long oblique diam¬ 
eter of the superior strait. But even after descent has occurred, all ob¬ 
stacles to labor have by no means been overcome, since in many cases 
the inward projection of the ischium may lead to abnormalities in 
rotation. Generally speaking, these pelves are not excessively con¬ 
tracted, Prouvost reporting that 40 out of the 50 cases of labor com¬ 
plicated by them ended spontaneously. 

Treatment.— Although the pelvic contraction is usually not very pro¬ 
nounced, serious dystocia may occur. For this reason the patient should 
be examined under anesthesia during the last weeks of pregnancy and 
the entire interior of the pelvis carefully palpated. If it appears probable 
that engagement will not occur, cesarean section should be performed 
before the onset of labor. Fortunately, this is rarely indicated, unless 
the foetus is large, or the history of previous labors has shown that the 






890 


PELVIC ANOMALIES—ATYPICAL DEFORMITIES 


birth of a living child is out of the question. \\ hen the obstacle to the 
engagement of the head is not serious, version gives better results than 
forceps. This is especially true in coxalgic pelves when the ankylosed 
leg and asymmetry of pubic arch may make the application of the 
latter extraordinarily difficult. 

Pubiotomy is not a justifiable operation in coxalgic pelves, as we 

have no means of deter- 



Fig. 048. —Side and Rear View of Patient with 
Bilateral Luxation of Femora. 


layed and deficient ossification of the base 


mining in advance whe¬ 
ther the sacro-iliac syn¬ 
chondroses are synos- 
tosed; and if such be the 
case the operation cannot 
lead to a satisfactory in¬ 
crease in the capacity of 
the pelvic canal. 

Coxarthrolisthetic Pel¬ 
vis. — Very exceptionally 
as the result of localized 
softening in the region of 
the acetabulum, the base 
of one or both acetabula 
yields to the pressure 
exerted by the head of 
femur, and projects into 
the pelvic cavity, thus 
leading to a uni- or bi¬ 
lateral transverse con¬ 
traction, which when pro¬ 
nounced may give rise 
to serious dystocia. Ep- 
pinger, who studied the 
condition exhaustively in 
1903, designated such 
pelves as coxarthrolis¬ 
thetic, and attributed 
their production to de- 
of the acetabulum. The 


deformity was known to A. W. Otto as early as 1824, and Breus and 
Kolisko have shown that it is usually dependent upon gonorrheal coxitis, 
instead of upon arthritis deformans or tubercular processes, as was for¬ 
merly believed. Chiari, however, in 1912, described a specimen which 
he held resulted from tabetic arthritis. The condition is rare, and 
Waller succeeded in collecting only 1(> cases up to 1922. 


PELVIC DEFORMITY DUE TO BILATERAL LAMENESS 

Occasionally children are born with luxation of both femora , the 
heads of the bones lying, as a rule, upon the outer surfaces of the iliac 
bones, above and posterior to their usual situation. In some cases the 








PELVIC DEFORMITY DUE TO 


BILATERAL LAMENESS 


897 


acetabula are entirely absent, but more frequently they are present 
in a rudimentary condition, new but imperfect substitutes being formed 
higher up. Strange to say, the condition does not usually seriously in¬ 
terfere with the individual in the matter of learning to walk at the 
usual age, though the gait, is more or less wabbly. 

The pelvic changes resulting from this condition have been studied 
particularly by Kleinwachter, Schauta, and Sassmann, the latter writer 
having collected 27 cases from the literature. Owing to the fact that 
the upward and inward force exerted by the femora is not applied in its 


usual direction through the 
acetabula, the pelvis becomes 
unduly wide, and more or less 
flattened anteroposteriorly. 
The transverse widening is 
particularly marked at the in¬ 
ferior strait, while the flatten¬ 
ing, as a rule, is not very pro¬ 
nounced. Thus, the conjugata 
vera usually measures between 
9 and 10 centimeters, and Del- 
mas, after studying 17 cases, 
concludes that the various di¬ 
ameters are usually enlarged 
unless the condition is compli¬ 
cated by some other abnormal¬ 
ity. Hence, this pelvis rarely 
offers any serious obstacle to 
labor. 

The patient presents a 
characteristic appearance, 



which is suggestive of that ob- 


. Fig. 649. —Obstruction of Pelvic Canal by 
Served in spondylolisthesis. Cystic Enchondroma (Zweifel). 

Owing to the displacement of 

the femora the trochanters are more prominent than usual, and the width 
of the buttocks is increased. At the same time, owing to the inciease 
in the pelvic inclination, there is marked lordosis, the back of the 
patient appearing considerably shortened and presenting a marked 

saddle-shaped depression just above the sacrum. 

Meyer described a pelvis obtained from an individual who had 
double club-foot ,. and found that it was markedly funnel-shaped. This 
condition he attributed to the absence of the usual spring at the foot and 
ankle-joints, and to the fact that the knees were held fixed during 
walking Accordingly, with each step a distinct shock was imparted 
to the acetabula, instead of the more gentle force which is exerted under 

ordinary circumstances. 






898 


PELVIC ANOMALIES—ATYPICAL DEFORMITIES 


ATYPICAL DEFORMITIES OF THE PELVIS 

In rare instances the pelvis may be more or less deformed by the 
presence of bony outgrowths at various points, and less frequently by 
tumor formations. Exostoses are most frequently observed upon the 
posterior surface of the symphysis, in front of the sacro-iliac joints, 01 
upon the anterior surface of the sacrum, though in occasional cases they 
may be formed along the course of the iliopectineal line. 

Kilian, in 1854, directed attention to the fact that such structures 
may form sharp, more or less knifelike projections. He designated the 
condition as acananthopelys or pelvis spinosa. Such formations are rarely 
sufficiently large to offer any obstacle to labor, but owing to their peculiar 
structure may do considerable injury to the maternal soft parts. In 
fact, in several of the cases reported, they have cut through the lower 
portion of the uterus. 

In rare instances callus formation , resulting from inflammatory 

processes within the 
pelvis, may attain such 
proportions as to lead 
to serious pelvic ob¬ 
struction, as in a case 
reported by Ahlfeld. 

Tumor formations 
of various kinds may 
spring from the walls 
of the false or true 
pelvis and so obstruct 
its cavity as to render 
labor impossible. Fi¬ 
bromata, osteomata, 
enchondromata, carci¬ 
nomata, and osteosarcomata of the pelvis have been described, and some¬ 
times assume very considerable proportions, and occasionally become 
cystic. Stadfeld was able to collect 49 such cases in 1879, and Goder 
81 cases in 1895. Enchondromata occur more frequently than other 
varieties of tumor formation, Schopping being able in 1907 to collect 
33 well-described cases from the literature. He pointed out that such 
tumors grow especially rapidly during pregnancy and give rise to serious 
dystocia; 21 cesarean sections and 3 destructive operations being neces¬ 
sary in his series of cases. 

L T nless cesarean section is performed, the prognosis is very grave 
when the pelvis is obstructed by tumors from its walls, 50 per cent, of 
the mothers and 89 per cent, of the children having perished in the 
cases collected by Stadfeld, while in onlv 11 cases was labor terminated 
by spontaneous delivery, forceps, or version. 

In rare instances healed fractures of the pelvis may offer an in¬ 
superable obstacle to the birth of the child, owing either to an excessive 
formation of callus or to the projection of the broken ends of the bones 



Fig. 650.—Fractured Pelvis (Mars). 



LITERATURE 


899 


i nto the pelvic cavity. This condition, however, is very rare, as it is 
dated that only 0.8 per cent, of all fractures involve the pelvis, and in 
|such cases the internal injuries are usually so severe as to lead to the 
leath of the patient, so that only a small proportion of such women 
survive, and very few of them become pregnant. 

The effect upon labor depends upon the location of the fracture and 
ts manner of healing. Fig. 651 shows a pelvis described by Mars, and 
.rives an idea of the extent of the changes which sometimes result. In 
i case reported by Neugebauer, in which there was a transverse fracture 
}f the second sacral vertebra, the vertebral column prolapsed into the 
pelvic cavity and gave rise to a deformity suggestive of spondylolisthesis. 
For further details the reader is referred to the articles of Schauta, 
Tarnier, Meurers, and Breus and Kolisko. 


LITERATURE 

A.HLFELD. Das durch Knoehenauswiichse verengte Becken. Lehrbuch der Geburts- 
hiilfe, II. Aufl., 1898, 336. 

Breus mid Kolisko. Coxitis-Becken. Die path. Beckenformen. Leipzig u. Wien, 
1912, iii, 474-593. 

Briggs. The Coxalgic Pelvis. J. Obst. and Gyn. Brit. Emp., 1914, xxvi, 212-215. 
Ohiari. Pelikologisclie Mittheilungen. Yerh. d. deutschen path. Gesellsch., 1912, 
xi, 318-337. 

Delmas. Sur l’anatomie obst. du bassin a luxation coxo-femorale congenitale 
double. L 7 obstetrique, 1911, N. S. iv, 729-746. 

Eppinger. Pelvis-Chrobak, Coxarthrolisthesis-Becken. Beitrage z. Geb. u. Gyn. 

Wien, 1903, ii, 173-235 (Chrobak’s Festschrift). 

Goder. Yon dem Becken ausgehende Tumoren als Geburtshinderniss. D. I., Halle, 
1896. 

Kilian. Das Stachelbecken (Akanthopelvs) ; Schilderungen neuer Beckenformen. 
Mannheim, 1854, 59-114. 

Kleinwachter. Das Luxationsbecken, etc. Prager Vierteljahrsschr. f. Heil- 
kunde, cxviii, cxix. 

Mars. Schragverengtes Becken infolge einer Fractur. Archiv f. Gyn., 1889, 
xxxvi, 289-300. 

Meurers. Beitrag zur geb. Bedeutung der Frakturbecken. D. I., Heidelberg, 
1904. 

Prouvost. Etudes sur les bassins vicies par boiterie. These de Paris, 1891. 
Sassmann. Das Becken bei angeborener doppelseitiger Hiiftgelenksluxation. 

Archiv f. Gyn., 1873, v, 241-267. 

Schauta. Miiller ’s Handbuch d. Geb., 1889, ii. 

Die Beckenformen bei doppelseitiger Luxation der Schenkelkopfe, 466-472. 

Die Beckenform bei Klumpfuss, 472-473. 

Schopping. Das Becken-enchondrom, besonders als Geburtshinderniss. Monats- 
schr. f. Geb. u. Gyn., 1907, xxv, 845-874. 

Stadfeld. Die Geburt bei Geschwiilsten des Beckens. Zentralbl. f. Gyn., 1880, 
iv, 417-420. 

Tarnier et Budin. Traite de Part des accouchements. Paris, 1898, iii. 
Malformations du bassin dans la claudication, 229-278. 

Deformations atypiques du bassin, 338-352. 

Waller. Ein Becken von Otto-Chrobak mit fractura acetabuli. Deutsche Zeitschr. 

f. Chirurgie., 1922, clxviii, 19-36. 






CHAPTER XXXIX 


DYSTOCIA DUE TO ABNORMALITIES IN DEVELOPMENT OR 
PRESENTATION OF THE FCETUS 

EXCESSIVE DEVELOPMENT 

As was stated in Chapter V, the child at birth rarely exceeds 1 
pounds (5,000 grams) in weight, though authentic accounts of mu( 
larger infants are to be found in the literature. 

Provided the pelvis is not contracted, it is very exceptional for 
normally formed child, weighing less than 10 pounds (4,500 grams), j 
give rise to dystocia by its mere size. In overdeveloped children tl 
difficulty is generally due to the fact that the head tends to becon 
not only larger but harder, and consequently less malleable, with increa 
ing weight; although it sometimes happens that after the head In 
passed through the pelvic canal without difficulty the dystocia may 1 
due to the arrest of the unusually large shoulders either at the pelv 
brim or outlet. 

Excessive development of the foetus can unusually be traced to one ( 
four causes: prolongation of pregnancy, large size of one or both parent 
advancing age, or multiparity of the mother. 

Cases in which three hundred days or more elapse between the la: 
menstrual period and the onset of labor are not uncommon, and i 
the case of Gaskill versus Gaskill the English Courts in 1921, aft* 
hearing competent expert testimony, decided that a child was legitimai 
which had been born 331 da vs after the last coitus. Ovamada stat< 
that the possibility of prolonged pregnancy was present in 11 per cen 
of the 932 children born in the Munich clinic between the years 18S 
and 1910 whose weight exceeded 9 pounds (4,000 grams). In tl 
majority of such cases, however, the prolongation is only apparent, an 
is dependent upon the forgetfulness of the patient concerning the dai 
of the last menstruation. In this event, however, the size of the chil 
does not greatly exceed the average. On the other hand, actual pr( 
longation occasionally occurs, and I can recall several cases in whic 
eleven lunar months had elapsed between the last menstrual period an< 
the birth of an excessively large child. In such circumstances serion 
dystocia may arise, inasmuch as the child may increase in size for eac 
day beyond full term that it remains in the uterus. Accordingly 
whenever labor fails to occur within a few days of the calculated date 
the patient should be carefully examined twice each week, and labo 
induced as soon as one is convinced that full development has bee 
attained. 


900 









EXCESSIVE DEVELC)PMENT 


901 


More frequently the excessive size of the child is due to the fact 
hat one or both of its parents are unusually large; moreover, it is a 
natter of common observation that the foetal head in many instances 
esembles that of its father, large-headed men usually producing children 
rith similar characteristics. Likewise, the age of the mother may have 
m important influence upon the foetal development. Thus, the children 
>f elderly primiparae frequently exceed the ordinary average, and in 
nultiparae the children are often larger with each successive pregnancy, 
irovided they do not follow in too rapid succession. 

As a rule, large children have well ossified skulls. This is more par- 
icularly true for males, in whom the biparietal diameter is usually some¬ 
what greater than in female children of the same weight. In such cases 
he inability of the head to become molded not only interferes with its 
ngagement, but predisposes to certain injuries, such as spoon-shaped 
i lepressions of the skull, if artificial delivery becomes necessary. 

Although, in the case of a normal pelvis, a moderate increase in the 
ize of the child is usually without great practical significance, when any 
legree of contraction exists such a condition may make all the differ- 
1 nee between an easy and a difficult labor. At the same time, in mul- 
' iparous women the dystocia is often due in great part to the loss of 
8' one of the uterine musculature incident to repeated childbearing. On 
he other hand, it should always be remembered that quite as serious 
i ystocia may arise when an excessively large head attempts to pass 
hrough a normal pelvis, as when a head of average size is arrested by 
markedly contracted superior strait. 

Inasmuch as our means of determining the size of the child, and par- 
icularlv of its head, are far from accurate, the diagnosis of excessive de- 
elopment is, as a rule, not established until after fruitless attempts at 
elivery have been made. Nevertheless thorough examination, in which 
areful palpation and Muller’s method of impression are employed, 
hould ordinarilv enable the trained obstetrician to arrive at fairly ac- 
urate conclusions and prepare him to meet this complication. If the 
ielvis is normal the failure of engagement in the last weeks of pregnancy 
n a primipara, or the existence of a face, brow, or transverse present a- 
|ion, should suggest the possibility of excessive size of the child. 

Treatment.—If the patient has apparently gone beyond term, and 
xamination shows that the size of the child is above the average, there 
hould be no hesitancy in the immediate induction of labor as a prophy- 
ictic measure. In multiparous women with normal pelves whose history 
hows that excessive foetal development w r as the cause of the previous 
ifficult labors, the size of the child may occasionally be regulated by 
estricting the use of carbohydrates during the last two months of preg- 
ancy. If this does not have the desired result, labor should be induced 
s soon as the child has attained a normal size. On the other hand, if 
he pregnancy is not prolonged, the condition is rarely suspected by t tie 
rdinary practitioner before the outset of labor, and the diagnosis is 
aade only after Nature has shown that she is unable to effect delivery, 
t is however, exactly in this type of case that the benefits of efficient 
•renatal care becomes manifest. If the patient is carefully palpated 








902 


DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 


at intervals during the last months of pregnancy, and weekly if th 
child is not born within one week following the calculated date of de 
livery, excessive size of the child will rarely escape recognition. Ii 
several instances, I have done cesarean section solely on that account 
and every few weeks I induce labor when the child has attained some 
what more than the average size, because I feel that it is irrational t 
allow it to grow sufficiently large to cause actual dystocia. 

Zangemeister and Lehn in 1918 studied the obstetrical significanc 
of excessively large children, and, while they found that ordinarily ; 
weight less than 4,500 grams (10 pounds) does not give rise to dystocia 
they stated that the chances of the child being born alive decrease 
progressively with each additional 500 grams. Accordingly, prophylacti 
treatment is the ideal in these, as well as in so many other obstetrical 
circumstances. If, however, the complication has not been recognize< 
until the patient is well advanced in labor, it is often difficult to de 
termine the best method of procedure. If examination shows that th 
head is not engaged and that the disproportion is excessive, the propriet 
of cesarean section or pubiotomy should be considered, provided thalj 
unavailing attempts at delivery have not been made. On the othe 
hand, if physicians with questionable technic have failed to effect de 
livery by forceps or version, radical surgical interference is contra 
indicated, and craniotomy becomes our sole resource. 

When excessive size of the shoulders prevents the delivery of th 
child after birth of the head, labor can often readily be terminated afte 
diminishing the size of the shoulder girdle by cutting through the clavi t 
cles with a pair of heavy scissors— cleidotomy. 

MALFORMATION OF THE FCETUS 

Double Monsters. —For practical purposes 3 groups of double mon 
sters may be distinguished: (1) Incomplete double formations at th 
upper or lower half of the body (diprosopus, dipagus) ; (2) twins whic 
are united together at the upper or lower end of the body (craniopagm 
ischiopagus, or pygopagus) ; (3) double monsters which are united by th 
trunk (thoracopagus and dicephalus). t. 

The diagnosis of any one of these conditions is not made until diff 
culty experienced in attempting delivery has led to careful exploratio. 
under anesthesia with the entire hand in utero, although the existenc 
of a multiple pregnancy may have been suspected. As such monstrositie 
frequently present minor deformities as well, the detection of a clut 
foot, hare-lip, etc., should direct one’s attention to the possible existenc 
of some still more serious abnormality. E 

Fortunately the delivery of many monstrosities is much more readil 
accomplished than would appear possible at first sight. In the firs 
place, such pregnancies rarely go on to full term, so that the monstrosit 
rarely exceeds a normal child in size. In the second place, the conne( 
tion between the two halves is often of such a character as to permi 
of sufficient motility between the component parts as will make thei 
successive delivery possible. 







DEFORMITIES OF FCETUS 


903 


On the other hand, in the first group the large size of the doubled 
portion of the monster may lead to serious mechanical obstacles at the 

v ^ liead in a diprosopus is, as a rule, much 

t nore readily delivered when it forms the after-coming part than when 
6 it presents primarily. In the second group a craniopagus presenting by 
t ( :he head usually causes only a moderate amount of difficulty; whereas, 
>n the other hand, ischiopagi and pygopagi, as a rule, call for complicated 
Hnd difficult maneuvers before delivery can be effected. 

In the third group, the delivery of dicephalic monsters is facilitated 
a vhen they present by the breech, as in many cases first one and then 
' he other head can be extracted. On the other hand, in cephalic presen- 
l! at ions the two heads may mutually interfere with one another and thus 
1 >revent engagement until one has been diminished in size by craniotomy. 

1 -Vhen engagement of one head occurs delivery can be partially effected by 
creeps, but as a rule the head cannot be delivered beyond the pubic 
* trch for the reason that further descent is prevented by the arrest of 
he second head at the superior strait. Under such circumstances it is 
dvisable to amputate the first head, after which delivery of the rest 
f the monster is, as a rule, best accomplished by version. 

Thoracopagi usually offer a less serious obstacle to delivery, for the 
fl eason that they are frequently so loosely connected with one another 
hat considerable motility is possible. Indeed, it is not unusual for the 
wo children to present in a different manner. When possible, it is advis- 
ble to bring down all four feet at the same time, and to effect extraction 
n such a way that the posterior head is first delivered. In cephalic 
resentations the head and body of the first child are expelled, and the 
econd child is then born very much as in an ordinary twin pregnancy, 
f, however, the latter presents transversely, its delivery can be effected 
nly by version and extraction. 

m 


DEFORMITIES OF FCETUS 

In this place attention will be directed only to those abnormalities in 
oetal development which may give rise to difficult labor. An clccu dincus 
J I a monster which is sometimes developed in single-ovum twin pregnan- 
ies as the result of inequalities in the communicating placental ciicula- 
ion. One twin is w T ell developed and normal, while the othei is im- 
erfectly formed, and either possesses a rudimentaiy heart or no heait at 
LI, being designated according to Kehrer as hemiacardius oi holo 
Tardius, respectively. The genesis of such conditions was considered 

l the chapter on Multiple Pregnancy. 

The holoacardiac monsters may occur as acephali, amoiphi, ox acornn. 
>f these the most common variety is the acephalicus or headless foetus, 
-ess common is the amorphous monster, which possesses neither a head 

J or extremities, but is round in shape and presents upon its surface a 
umber of small nodules, which represent the rudimentary extremities, 
the umbilical cord may be attached to any portion of its surface, 
he interior of the monstrosity contains a rudimentary intestinal tract, 







904 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 


cystic cavities, vertebrae, etc., but no trace of a heart. The rarest variet 
of acardiacus is the acormus or trunkless monster, which consists of a 
imperfectly developed head and a rudimentary body, the umbilical cor 
being attached to the cervical region. 

As a rule such monsters do not attain any notable size, although e:x 
ceptionally, as the result of obstruction in the umbilical vein, they ma 
become edematous and give rise to dystocia. 

The anencephalus or hemicephalus is a monster possessing a trunl 
but only an imperfectly developed head, from which a large part of th 
brain and skull is lacking. Ordinarily such beings are of moderate siz< 
but occasionally the shoulders may be so excessively developed as to giv 



rise to serious dystocia. 

Owing to the absence of the cranial vault the face is very prominer 
and somewhat extended, the eyes often protrude markedly from thei 
sockets, and the tongue hangs from the mouth. The brain is in a rud 
mentary condition, and the base of the skull is accessible to the examir | 
ing finger, so that the sella turcica can be distinguished. Owing to th j 
exposed condition of the base of the brain and the upper part of th 
medulla, there is frequently a marked increase in the amount of amnioti i 
fluid, its production being analogous to that noted in the picure exper 
ments of the physiologists. 

In view of the abnormal shape of the head, face presentations ai 

frequently observed, while those of tl 
vertex are less common than with 
normal foetus. Transverse and fo< 
presentations are likewise not unusua 
When the monstrosity presents 1 
the face or head a correct diagnosis 
frequently made by vaginal touch, tl 
characteristic bulging of the eyes bein 
noted in the former, and the absen< 
of the cranial vault and the present 
ol the sella turcica in the latter presei 
tation. 

Delivery, as a rule, occurs muc 
more readily when the monster pr< 
sents by the breech, for the reason tin 
the imperfectly developed head is n( 
an efficient dilating agent, though i 
mam cases lapid and spontaneous delivery is observed. Even when tl 
enknged shoulders give rise to dystocia, delivery can usually be accon 
pushed by means of version without any great difficulty. 


Fig. 651. —Anencephalus. 


HYDROCEPHALUS 


In this not very rare condition, the cerebral ventricles are distende 

hv an excessive amount of cerebrospinal fluid (Fig. 652) which accon 

mg to the researches of Dandy and Blackfan, is due to the obliterate 














HYDROCEPHALUS 


905 



of Magendie s foramen. As a result the skull becomes much increased 
m size, frequently attaining several times its normal dimensions, while 
the brain substance forms a layer only a few millimeters thick beneath 
it, but occasionally it has entirely disappeared, except for a few tags 
of tissue in the neighborhood of the central ganglia. At the same time 
the cranial hones are imperfectly developed, the sutures and fontanelles 
being much wider than usual. 

If the enlarged head is not tensely filled with fluid, under the influ- 
mce of the uterine contractions it may undergo such changes in shape 
jhat its spontaneous expulsion becomes possible. This, however, is so 
aie a possibility that it should not be reckoned with in determining the 
reatment to be pursued in a given case. Still less frequently, owing to 
he pressure to which the head is subjected at the time of labor, the 
issues forming a fontanelle or suture may give way, so that the cerebro- 
pinal fluid can escape, after which the head collapses and spontaneous 
leli\eiy becomes possible. In the vast majority of cases, however, the 

condition gives rise to serious dystocia, 
which if not promptly relieved will lead to 
rupture of the uterus and the death of 
the patient from intra-abdominal hemor¬ 
rhage. 


Fig. 652. —Dystocia Due to Hydrocephalus (Bumm). 


In hydrocephalic children, although cephalic presentations predomi- 
late, owing to the lack of accommodation between the head and the 
>elvic canal, the breech is often substituted. 

Diagnosis.—As a rule the condition is not recognized until several 
lours of fruitless second-stage pains have demonstrated the existence of 
m obstacle to delivery. On the other hand, careful examination should 
irdinarily lead to a correct diagnosis during the last weeks of pregnancy 
>r soon after the onset of labor. In many cases the deformity can be 
letected by external palpation, the immensely large and movable head 
>eing isolated above the superior strait or in the fundus of the uterus, 
furthermore, the examiner should always be on the lookout for the 










906 DYSTOCIA DUE TO ABNORMALITIES OF THE F(ETUS 


presence of fluctuation, while a peculiar crackling sensation can b 
elicited by pressure upon the skull. I have made a positive diagnosi 
in this manner upon several occasions without an internal examina 
tion. 

As soon as the cervix is dilated, vaginal examination will reveal 
large head with widely gaping sutures, through which fluctuation ca 
he obtained by appropriate maneuvers. Of course this does not hok 
good in breech presentations, but here ’abdominal palpation will revea 
the presence of the large fluctuant head in the fundus of the uterus, o 
just above the superior strait, in case attempts at extraction have bee: 
made. 

Prognosis.—For the child the outlook is uniformly bad, for even i 
horn alive it usually succumbs within a few days, or, in the rare cases i 
which it survives, grows up a hopeless idiot. The maternal prognosi 
depends largely upon the obstetrician. If left to Nature the usual tex 
mination is rupture of the uterus ; whereas, if the condition he detected 
and the proper treatment instituted, the results are almost universal! 
favorable. 

Treatment.—As soon as the cervix has become completely dilated th 
head should be perforated through one of the wide sutures, in order tha 
the cerebrospinal fluid can escape and the skull collapse, after which de 
livery can be effected by the unaided efforts of Nature, or may b 
accelerated by the employment of the cranioclast. In breech presenta 
tions, when the head has been arrested at the superior strait, evacuatio: 
of its contents can be readily effected by excising the arch of one of th 
cervical vertebrae and passing a catheter through the vertebral canal 
On account of the nature of the disease and its effect upon the chile 
craniotomy may be undertaken without hesitancy, even by those wh 
ordinarily do not consider it a justifiable procedure. 

In evacuating the hydrocephalic head, it should he borne in min' 
that, owing to the extreme thinness of the brain, mere perforation i 
not necessarily synonymous with foetal death. For this reason th 
perforator should be carried to the base of the skull and vigorousl 
manipulated in order to destroy the medulla, as nothing could be mor 
horrible than the extraction of a living child after such an operation. 

I ) j 
1 In 

ENLARGEMENT OF THE BODY OF THE FCETUS 


Enlargement of the abdomen sufficient to cause grave dystocia i 
usually the result of ascites, a very much distended bladder, or of tumor 
of the kidneys or liver. 

Whenever the abdominal distention is excessive- spontaneous labor i 
out of the question; but unfortunately the condition usually escapes de 
tection until fruitless attempts at delivery have demonstrated the exist 
ence of some obstruction and have led the obstetrician to introduce hi 
entire hand into the uterus in the hope of discovering its nature. 

Occasionally a foetus affected with general dropsy may attain sucl 
immense proportions that spontaneous delivery is impossible. A numbe 






ENLARGEMENT OF THE BODY OF THE FCETUS 


907 



i of ® U ® h case * ar ® recor <Jed m the monographs of Ballantyne, Schumann, 
' and Borland. In very rare instances the ascites associated with fatal 
■ peritonitis may have a similar result, and exceptionally a child suffering 

from chondrodystrophia fatalis may become so edematous as to give rise 
to dystocia, 


As the result of the di¬ 
latation of the superficial 
lymphatics associated with 
edema of the subcutaneous 
e j tissues, the foetus may as¬ 
sume immense proportions 
and take on a bizarre shape. 
This condition, which is 
designated as elephantiasis 
congenita cystica, has been 
studied in detail by Ballan¬ 
tyne, and is a very rare 
cause of difficult labor (Fig. 
653). 

Defective development of 
the lower portion of the 
urinary tract may lead to 
the retention of urine ac¬ 
companied by distention of 
the abdomen sufficient to 
render normal delivery im¬ 
possible (Fig. 654). Ex¬ 
amples of this condition 
have been reported by 
Walt her, Schwyzer, and 
others, who also give details 
as to its etiology. 

A more frequent cause 
of abdominal enlargement is 


Fig. 653. —Elephantiasis Congenita Cystica 

(Ballantyne) 


the presence congenital cystic kidneys. The growth, which is histo¬ 
logically an adenocystoma, may involve one or both organs, and give 
rise to tumors of immense size. The condition is frequently associated 
with dilatation of the ureters, and with dropsical effusions into the 
carious body cavities. Fig. 655 gives an idea of the extent of the 
abdominal enlargement in a child which I delivered, and which was 
described by Lynch in 1906, together with an analysis of 50 other 
?ases reported in the literature. 

In rare cases the abdominal enlargement may be due to tumors of 
he liver, Porak and Couvelaire having reported a case of congenital 
*ystic liver associated with a similar condition of the kidneys. More- 
>ver, large tumors, arising from any of the abdominal organs, may give 
•ise to dystocia. Thus, Rogers has described an immense fibrocystic 
esticle, and Phaenomenow an aortic aneurysm so large as to interfere 
cith delivery. In rare instances foetal inclusions, such as the so-called 






908 


DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 




Fig. 654. 


-Fcetus with Immensely Distended Bladder 
(Hecker). 


F 


fcetus in foetu, may be 
responsible. Occasion¬ 
ally the invasion bj 
Bacillus aerogenes cap- 
sulatus may be followed 
by such an extensive 
production of gas that 
the size of the fcetus be¬ 
comes more thar 
doubled, when spon¬ 
taneous delivery is im¬ 
possible. 

In all of these con¬ 
ditions, if the dystocia 
is marked, delivery car 
be accomplished onh 
after opening the bod} 
of the foetus and allow 
ing the fluid to escape, or removing a portion, at least, of the offending 
tumor formation. The 
latter operation is not 
always easy, for, owing 
to the constrained 
position of the hand 
in utero and the dense 
consistency of the 
growth in many cases, 
great difficulty may be 
experienced. 

In rare instances 
abnormal growths aris¬ 
ing from various por¬ 
tions of the body of 
the fcetus may inter¬ 
fere with delivery. 

Cases are on record in 
which lipomata, car¬ 
cinomata, angiomata, 
and various other 
tumors have given 
rise to such an en¬ 
largement that spon¬ 
taneous delivery be¬ 
came out of the ques¬ 
tion. Exceptionally, 
dermoid cysts and 
teratomatous tumors 
about the perineum 

and sacrum may offer a serious obstacle. Fig. 275 represents a fcetus] 


L_ 


/rx x. 


Fig. 655.—Fcetus with Congenital Cystic Kidneys. 




















909 


DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 

in which an adenoma of the thyroid gland necessitated a destructive 
operation. In rare instances, a large umbilical hernia, a spina bifida 
and other growths give rise to difficult labor. 


DYSTOCIA DUE TO ABNORMAL PRESENTATIONS OF THE 

FCETUS 


Transverse Presentations.— In this condition the long axis of the 
foetus crosses that of the mother at about a right angle. When it forms 
an acute angle we speak of an oblique presentation. The latter, however, 
is usually only transitory, becoming converted into a longitudinal or 
ti ansi else presentation when labor supervenes. 

In transverse presentations the shoulder usually occupies the superior 
strait, the head lying in one and the breech in the other iliac fossa 



Fig. 657. —Diagram Showing Right 
Acromion Dorso-anterior Presen¬ 
tation. 


Fig. 656. —Diagram Showing Left 
Acromion Dorsoposterior Presen¬ 
tation. 



(Figs. 656 and 657). Accordingly, such a condition is commonly spoken 
of as a shoulder, less frequently as a lateral plane, and technically as 
an acromion presentation. The latter designation is chosen for the 
reason that the acromion process is one of the most characteristic features 
of the shoulder, the position being right or left according to the side 
of the mother toward which the acromion is directed. Moreover, as, in 
either position, the back may be directed either anteriorly or posteriorly, 
it is customary to distinguish between the dorso-anterior and dorso¬ 
posterior varieties. The recognition of the position of the back is of 
great importance in connection with the proper performance of version— 
the treatment par excellence in this condition. 

According to Schroeder, the shoulder is directed toward the left side 
of the mother 2.6 times more frequently than toward the right, while the 

I back looks anteriorly 2.5 times more frequently than posteriorly. 

Etiology. —The existence of a transverse presentation in a primipa- 
rous woman is prim a facie evidence of a lack of accommodation, usually 
the result of disproportion between the size of the head and the pelvis, 
though occasionally it may be due to hydramnios. In mnltiparae, on 









910 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 


the other hand, the most frequent etiological factor is abnormal relaxa¬ 
tion of the abdominal and uterine walls, the result of repeated child¬ 
bearing, which may be still further complicated by any of the causes 
already enumerated. Accordingly, transverse presentations are much 
more frequently observed in women who have borne a number of chil¬ 
dren, but in them, as a rule, the condition is less serious, for the reason 
that spontaneous reposition sometimes ensues after the onset of labor, 
the child assuming a longitudinal presentation—spontaneous version— 
whereas such an occurrence is very exceptional in primiparae. 

The occurrence of spontaneous version is very improbable after rup¬ 
ture of the membranes, and is still further hampered by any condition 
which interferes with the descent or engagement of the head; as, for 
example, a contracted pelvis, placenta previa, a pelvic tumor, or twin 
pregnancy. Very exceptionally, longitudinal may become converted into 
secondary transverse presentations at the time of labor, and such an 
occurrence is always indicative of disproportion between the size of the 
child and the pelvis. 

Diagnosis .—The diagnosis of a transverse presentation is usually 
readily made, inspection alone frequently causing one to suspect its 
existence. The abdomen is seen to be unusually wide from side to side, 
while the fundus of the uterus scarcelv extends above the umbilicus. 

On palpation the first, maneuver reveals the absence of a foetal pole 
from the fundus. On the second maneuver a ballottable head will be 
found in one and the breech in the other iliac fossa, while the third 
and fourth maneuvers are negative, unless labor has been in progress 
for some time and the shoulder has become impacted in the pelvis. At 
the same time the position of the back is readily determined. When 
it is situated anteriorly a hard resistant plane will be felt extending 
across the front of the abdomen; when it lies posteriorly irregular nodu- 
lations, representing the small parts, will be felt in the same location 
(Plate XV). 

On vaginal touch in the early stages of labor, the side of the thorax, 
readily recognizable by the “gridiron” sensation afforded by the ribs, can 
be made out at the superior strait. When dilatation is further advanced 
the scapula can be distinguished on one and the clavicle on the other side 
of the thorax, while the position of the axilla will indicate toward which 
side of the mother the shoulder is directed. Later in labor the shoulder 
becomes tightly wedged in the pelvic canal, and a hand and arm fre¬ 
quently prolapse into the vagina ; whether it is the right or left can be 
readily determined by ascertaining to which one of the obstetrician’s it 
corresponds, just as in shaking hands. 

Course of Labor .—With very rare exceptions the spontaneous birth 
of a fully developed child is impossible in persistent transverse presenta¬ 
tions, since expulsion cannot be effected unless both the head and trunk 
of the child enter the pelvis at the same time, which is manifestly impos¬ 
sible. Accordingly, both the foetus and mother must almost inevitably 
perish if appropriate measures are not instituted. On the other hand, 
small premature, and particularly macerated, children are frequently 
born spontaneously. 






PLATE XV 








PALPATION IN RIGHT ACROMIO-DORSO-ANTERIOR PRESENTATION. 


























911 


DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 


Throughout the first stage, but particularly during the early period 
of the second stage of labor, preliminary, but futile, preparations are 
made tor spontaneous delivery. These consist of a molding of the foetus 
in anticipation of the engagement of the presenting shoulder, which 
results in the approximation of the head to the ventral surface of the 
child, by which the transverse diameter of the foetal ovoid becomes 
diminished and the vertical diameter increased in length (Fig. 659) 
Aftei rupture of the membranes, if the patient is left to herself the 
shoulder is forced down into the pelvic cavity, and the corresponding arm 



Fig. 658. —Frozen Section through Woman Dying in Labor with a Neglected 

Transverse Presentation (Chiara). 


frequently prolapses. After a certain amount of descent, the shoulder 
becomes arrested by the margins of the superior strait, with the head 
in one iliac fossa and the breech in the other, and with the continuance 
of labor becomes firmly impacted in the upper part of the pelvic, ,cavity 
(Fig. 658). The uterus then contracts vigorously in the attempt to 
overcome the obstacle, but in vain. After a certain time the contraction 
ring rises higher and higher, the lower uterine segment becomes more 
and more stretched and eventually gives way, when a part or the whole 
of the product of conception escapes into the abdominal cavity. In such 
circumstances the patient usually succumbs within a short time to intra- 
peritoneal hemorrhage, while in other instances death occurs after a 
longer or shorter period from infection. 

Possibly once in many thousand cases, the uterus may cease to con¬ 
tract before the membranes rupture, and the child, being retained within 
the uterus, may eventually become mummified. Such a missed labor is 
very rare in human beings, though it is well known to the veterinarians. 
On the other hand, such an occurrence would be out of the question had 
the amniotic sac been opened, as in such circumstances bacteria w^oukl 
gain access to the uterus and give rise to infection, which, if not ter¬ 
minating in the death of the patient, would lead to the gradual casting 











912 


DYSTOCIA DUE TO ABNORMALITIES OF THE FCETITS 


off of the product of conception by suppurative processes, supposing that 

the woman could be so long neglected. 

In transverse presentations, now and again, spontaneous deliveiy 
ensues. Bartholin, in the seventeenth century, pointed out that a child 
that has lain transversely during the later months of pregnancy may 
spontaneously assume a longitudinal presentation at the time of labor. 
This so-called spontaneous version is not an infrequent occurrence. Its 
mode of production has already been referred to. 



Fig. 659. —Spontaneous Evolution by Douglas’ Mechanism. Moulding of Foetus 

and Impaction of Shoulder. X x h - 

A century later Roederer pointed out that in rare .instances, if the 
child be very small and the pelvis large, spontaneous delivery might occa¬ 
sionally be accomplished in spite of the persistence of the abnormal pre¬ 
sentation. In such cases the child becomes compressed upon itself with 
the head tightly pressed against the abdomen, so that a portion of the 
thoracic wall below the shoulder becomes the most dependent part and 
appears at the vulva. The head and thorax then pass through the pelvic 
cavity at the same time, and the child, which is doubled upon itself, 
is expelled —conduplicato corpore. Manifestly, such a mechanism is 
possible only . in the case of very small children, and is occasionally 
observed when the second child in twin pregnancy is prematurely born. 

In very rare instances, a dead child of moderate or average size may 
be expelled spontaneously by another mechanism, which is designated as 
spontaneous evolution. This, however, is met with so rarely, demands 
such peculiar conditions, and is attended by such risks to the mother 
that its occurrence should never be counted upon in actual practice, 
although very occasionally in neglected cases it may occur unexpectedly 
and even rapidly. Several cases have been observed in my service, two 



DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 


913 


| 





of^ which are described in Stephenson’s article, and in one of them a 
2,700 gram child was born eight hours after the onset of labor. 

Delivery by spontaneous evolution occurs once in every several hun¬ 
dred transverse presentations. It was first mentioned by Denman in 
1772 and its mechanism was accurately described by Douglas in 1811. 
Since then a considerable literature has accumulated upon the subject, 
and the articles of Payer, Zangemeister, Franz, and Stephenson deserve 
paiticulai mention. It is generally stated that spontaneous evolution 


Fig. 660. —Spontaneous Evolution by Douglas’ Mechanism. Prolapse of Arm and 

Elongation of Neck. X V3. 


may be effected by either of two mechanisms,—that of Denman or 
Douglas. Stephenson, however, after careful study of the original arti¬ 
cles, has concluded that only the latter occurs, and that the belief in 
the possibility of the former is based upon imperfect understanding of 
Denman’s casual and imperfect description of the process. 

In Douglas’ mechanism, the first stage consists in the molding of 
the foetus and impaction of the shoulder with prolapse of the arm, as 
described in a preceding paragraph. Then, under the influence of strong 
uterine contractions, the child rotates about its vertical axis, so that one 
side of the head comes to lie over the horizontal ramus of the pubis with 
the breech in the region of the opposite sacro-iliac joint, while the 
neck subtends the inner surface of the symphysis pubis (Fig. f»(30). Coin- 





914 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 

cident with excessive stretching of the neck, the prolapsed arm continues 
to descend until eventually the corresponding shoulder emerges under 
the pubic arch. The escape of the arm and shoulder affords room for 
the entrance of the rest of the body of the child into the pelvic cavity, 
and the lower side of the thorax, promptly followed by the breech, soon 
emerges from the vulva. Following the breech the anterior side of the 
thorax and the remaining arm are delivered, and finally the head is bom 
spontaneously, or is extracted manually, according to the exigencies of 

the case (Fig. 662). 



Fig. 661. —Spontaneous Evolution by Douglas’ Mechanism. Birth of Anterior 

Shoulder and of Buttocks. X l / z . 


In such cases the prolapsed arm is immensely swollen and a caput 
succedaneum develops over the presenting shoulder. From our studies 
it would appear that spontaneous evolution is possible only when the 
child is not unduly large and in the presence of strong uterine contrac¬ 
tions and an unusually elastic neck. Herrgott has reported an instance in 
which the child weighed 3,300 grams, and has collected the French liter¬ 
ature upon the subject up to 1918. Delivery by Douglas’s mechanism 
would probably have been effected in Chiari’s case had the patient sur¬ 
vived. 

Prognosis .—If spontaneous version does not occur within the first 
few hours after the onset of labor, and operative procedures are not 



915 


DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 

instituted spontaneous evolution offers the only possibility for spon¬ 
taneous delivery; and as this occurs so rarely as to be negligible the 
outcome for both mother and child is almost uniformly fatal, the child 
succumbing to asphyxia and the mother to hemorrhage or infection as 
a result of rupture of the uterus. On the other hand, if appropriate 
measuies are instituted, the prognosis for the child is fair, while for the 
mother it is excellent. In this class of cases prolapse of the cord is one 
ot the most frequent causes of foetal death. 



Treatment .—If the diagnosis has been made in the last month of 
pregnancy and the pelvis is approximately normal, cephalic version 
should be effected by external manipulations, and the child held in its 
new position by means of a properly fitting bandage. On the other 
hand, if the pelvis is markedly contracted, such a procedure is useless, as 
3esarean section at an appointed time will be the operation of choice. 

If the patient is not seen until after labor has set in external cephalic 
version should likewise be attempted, provided the membranes have not 
ruptured. As a matter of fact, however, such manipulations will usually 
move unsuccessful. In this event one should wait until the cervix is 
dmost completely dilated, and then, after rupturing the membranes, 
Derform internal podalic version, followed by prompt extraction. 











916 


DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 


On the other hand, if the patient be not seen until she is well ad¬ 
vanced in labor and the membranes have ruptured, the treatment will 
vary according to the degree of dilatation of the cervix, the condition of 
the patient, the degree of impaction of the shoulder, and the condition of 
the lower uterine segment. If the cervix is only partially dilated, while 
the child is alive and freely movable in the uterus, bipolar version may 
be attempted. After a foot has been brought down the cervix should be 
allowed to dilate still further before extraction is completed. On the 
other hand, if the condition is complicated by prolapse of the pulsating 



Fig. 663. —Frozen Section through Woman Dying at End of Pregnancy. Compound 

Presentation (Braune). 


cord, the cervix should be dilated manually, and the child extracted 
after internal podalic version. 

Whenever the cervix is fully dilated, internal podalic version should 
be performed at once, according to the rules already given, and followed 
by immediate extraction, provided the uterus is not so tightly contracted 
down over the child and the lower uterine segment so thinned out that 
such a procedure appears synonymous with rupture. Even in such cases 
anesthesia sometimes so relaxes the organ that version may be safely 
effected, although at first glance it had appeared to be out of the question. 

When the shoulder has become firmly impacted, the version appears 
to be contra-indicated, decapitation is the operation of choice, even if the 
child is alive; although very exceptionally cesarean section might be 
thought of. As such a condition is met with only in patients, who have 
been neglected by ignorant, and probably dirty, attendants, the danger 
of infection is so great that classical cesarean section should not be con¬ 
sidered. Consequently, if radical interference seems advisable, the body 
of the uterus should be amputated. For this reason, the procedure should 


_ 











DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 


917 


be limited to multiparous women; as in the case of primiparae it does 
not seem justifiable to destroy all future hope of childbearing for the 
sake of a child whose chances are already compromised. 

The treatment of transverse 
presentations again affords an 
admirable illustration of the 
advantages of efficient prenatal 
and intra-natal care. If the 
condition is recognized before 
or soon after the onset of labor, 
and intelligent medical care is 
available, the results for both 
mother and child are ideal; 
whereas if the patient is not 
seen until late in labor the 
mother is exposed to consider¬ 
able risk and the child will 
almost inevitably be lost; 
finally, if medical aid is not 
available, both mother and child will be lost. 

Compound Presentations.—By this term is understood the prolapse 
of an extremity alongside of the presenting part, both entering the pelvic 
canal simultaneously. It is not an infrequent occurrence, being observed 
about once in every 250 cases (Fig. 663). 

As a rule, a hand or an arm comes down with the head; much less 
commonly both arms, or a hand and a foot, or both feet may present 
together. Hahl has reported a case in which the neck of the child was 
girdled by its legs, so that the scrotum and head were felt upon vaginal 
examination (Fig. 665). 

Some idea of the relative frequency of the different combinations 
may be gained from the following table, taken from Pernice: 



Fig. 664.—Compound Presentation (Hahl) 


Head and hand. 

Head and arm. 

Head, hand, and cord. 

Head and both hands. 

Head, one hand, and one foot. 

Head, two hands, one foot, and cord 
Face, hand, and cord.. 


26 cases 
8 “ 

5 “ 

4 “ 

9 << 

dml 

1 case 

1 “ 


Such a condition is frequently associated with disproportion between 
the size of the head and the pelvis, owing to which early engagement 
has been interfered with, and as a result one or more of the extremities 
have prolapsed before the presenting part entered the pelvis. 

Treatment. —Whenever, during the first stage of labor, a hand is 
distinguished alongside of the head, it should be pushed up if possible, 
but if it be firmly fixed between the head and the pelvic wall it should 
be left alone, since it will usually not interfere with labor. On the other 
hand, if the entire arm is prolapsed alongside of the head, an effort 
should be made to replace it, provided serious disproportion is not present. 











918 


DYSTOCIA DUE TO ABNORMALITIES OF 


THE 


FCETUS 


If, however, any considerable difficulty is experienced, the attempt should 
be abandoned, and version performed. This is more particularly indi¬ 
cated, since if the arm retains its position it may give rise to serious 
dystocia, more especially if it extends around the child’s neck, consti¬ 
tuting the so-called nuchal 'position. 

When, as happens only rarely, the foot prolapses, attempts to replace 
it are usually futile, and version should be promptly performed, after the 
hand in utero has determined the exact condition of affairs. 


LITERATURE 

Ballantyne. General Foetal Cystic Elephantiasis. The Diseases of the Foetus. 
Edinburgh, 1892, i, 182-219. 

Bartholin. Quoted by Payer. 

Dandy and Blackfan. An Experimental and Clinical Study of Internal Hydro¬ 
cephalus. J. Am. Med. Assn., 1913, lxi, 2216-2217. 

Denman. Observations to Prove that in Cases where the Upper Extremities 
Present, at the Time of Birth, the Delivery may be Effected by the Spontaneous 
Evolution of the Child. London Med. J., 1785, v, 64-70 and 301-309. 

Dorland. Watery Accumulations in the Foetal Abdomen Obstructing Labor. Am. 
Jour. Obst., 1919, lxxix, 474-502. 

Douglas. An Explanation of the Real Process of the Spontaneous Evolution of 
the Foetus, etc. Dublin, 1819, ii, Ed. 

Franz. Zur Lehre von der Geburt mit gedoppeltem Koper. Gyn. Rundschau. 

Gaskill vs. Gaskill. The Law Reports, 1921, iii, Part XII, Dec. 5th., 1910, 
iv, 399-408. 

Hahl. St.rictur des os internum als Geburtshinderniss. Archiv f. Gvn., 1901, 
lxi ii, 684-694. 

Herrgott. Un cas d'evolution spontannee. Annales de gyn. et d’obst., 1918, xiii, 
193-203. 

Kehrer. Zur Lehre von den herzlosen Missgeburten. Archiv f. Gyn., 1908, lxxxv, 
121-138. 

Lynch. Dystocia due to Cystic Kidney. Surgery, Gyn. and Obst., 1906, iii, 
628-637. 

Oyamada. Ueber Ricsenkinder. Beitrage zur Geb. u. Gyn., 1911, xvii, 93-128. 

Payer. Zur Lehre von der Selbstentwickelung. Yolkmann’s Sammlung klin. 
Yortrage, 1901, N. F., Nr. 314. 

Peunice. Die Geburt mit Yorfall der Extremitaten neben dem Kopfe. Leipzig, 
1858. 

Phaenomenow. Beitrag zur Casuistik der durch die Frucht bedingten Geburts- 
hindernisse. Archiv f. Gyn., 1881, xvii, 133-139. 

Porak et Col\elaire. Foie polykystique cause de dystocie. Comptes rendus soc. 
d’obst., de gyn. et de paed. de Paris, 1901, iii, 26-37. 

Roederer. Quoted by Payer. 

Schroeder, Olshausen, und Yeit. Lehrbuch der Geburtshiilfe, XIII. Aufl., 1899, 
737. 

Schumann. A Study of Hydrops Universalis Foetus. Trans. Am. Gyn. Soc., 
1915, xl, 12-32. 

Sc hwyzer. Ueber einen Fall von Geburtshinderniss, bedingt durch hochgradige 
Erweiterung der fotalen Harnblase. Archiv f. Gyn., 1893, xliii, 333-346. 


LITERATURE 


919 


Stephenson., The Mechanism of Labor in Spontaneous Evolution. Bull. Johns 
Hopkins Hosp., 1915, xxvi, 331-335. 

Walther. Dystokie infolge ubermassiger Ausdehnung der fotalen Harnblase. 

Zeitsehr. f. Geb. u. Gyn., 1893, xxvii, 333-347. 

Zangemeister. Meehan ik und Therapie der in der Austreibungsperiode befind- 
lichen Querlagen. Leipzig, 1908. 

Zangemeister und Lehn. Die geburtshilfliche Bedeutung iibergrosser Frucht- 
entwickelung. Archiv f. Gyn., 1918, cix, 500-533. 







CHAPTER XL 


HEMORRHAGE 

Profuse hemorrhage occurring prior to or shortly after the birth of 
the child is always a dangerous and sometimes a fatal complication. 
Practically all varieties of antepartum hemorrhage, with the exception of 
those originating from lacerations of the genital canal, are due to a par¬ 
tial or complete separation of the placenta from its attachment to the 
uterine wall. This accident is an inevitable accompaniment of labor when 
the placenta is implanted in the neighborhood of the internal os—pla¬ 
centa previa, but occasionally occurs when the organ occupies its normal 
site in the upper portion of the uterus. 


PREMATURE SEPARATION OF THE NORMALLY IMPLANTED 

PLACENTA 

Antepartum hemorrhage due to the premature separation of the nor¬ 
mally implanted placenta has doubtless occurred from time immemorial, 
but its mode of production was first recognized by Louise Bourgeois in 
1609. Particular attention was directed to it in 1776 by Rigby, who 
clearly differentiated it from the hemorrhage due to placenta previa, 
and designated it as accidental, in contradistinction to the unavoidable 
hemorrhage associated with the latter condition. R. W. Holmes of 
Chicago proposed in 1901 to designate the process as ablatio placentae, 
and many have accepted his suggestion. 

As will be indicated below, the placenta may be completely or only 
partially detached from the uterine wall, and the effused blood may be 
entirely retained within the uterine cavity, or may escape externally 
through the vagina—concealed or external accidental hemorrhage. The 
former is one of the most serious accidents of pregnancy and labor, and 
fortunately occurs but rarely; while the latter is less serious, and in 
my experience occurs more frequently than hemorrhage due to placenta 
previa. Goodell in 1875 collected from the literature 106 instances of 
concealed accidental hemorrhage, demonstrated its great gravity, and 
indicated the impotence of the methods of treatment then in vogue. 
Indeed, it is in great part due to his teaching that it has been assumed 
fhat concealed hemorrhage and premature separation of the placenta 
are synonymous, with the result that the frequency of the latter has been 
underestimated and its seriousness exaggerated. Holmes in 1901 was 
able to collect 200 additional cases, but believed that his figures gave a 
■^er\ inadequate idea of the incidence of the accident. Subsequent in- 

920 


PREMATURE SEPARATION OF THE PLACENTA 


921 


vestigation has proved the correctness of his prediction, and Dorman, 
Colclough and Essen-Moller in large series of cases observed premature 
separation of the placenta once in every 115, 207 and 216 labors, re¬ 
spectively; although clinical symptoms were lacking in one half of 
their cases, while concealed hemorrhage occurred in less than one case 
out of ten. In the last 2,000 patients delivered in my service prior to 
July, 1915, 17 cases of premature separation were noted, but only one 
example of concealed accidental hemorrhage occurred in a series of 15,000 
labors. 

Etiology.—Unfortunately the primary cause of premature separation 
of the placenta is imperfectly understood, and the following conditions 
have been invoked as etiological factors: traumatism, shortness of the 
umbilical cord, profound mental emotions, endometritis, nephritis, tox¬ 
emia, and torsion of the uterus. Formerly it was held that a fall or a 
blow upon the abdomen might cause it, and traumatism was noted in 67 
of the cases collected by Ilolmes, but was mentioned less frequently in 
the statistics of subsequent Writers, and was lacking in all of my own 
cases. For this reason, I believe, that its influence has been exaggerated, 
and, while it may occasionally be concerned, it cannot be regarded as 
the usual cause of the complication. In the classical specimen of Pinard 
and Varnier, the accident was clearly due to traction exerted upon the 
placenta by an abnormally short umbilical cord. Gardiner has laid great 
stress upon its importance, but as such an abnormality is lacking in most 
instances, it is evident that it can only exceptionally be an etiological 
factor. The older writers laid great stress upon the part played by 
sudden and intense mental emotions, but at present no one believes in the 
efficacy of such causes. 

Many recent German authorities, particularly Weiss, Seitz and 
Schickele, hold that inflammatory or degenerative lesions in the decidua 
are responsible for the production of the accident. Doubtless, such 
changes are sometimes present ; but as they were absent in all of my 
specimens, I feel that they should be regarded as accidental complica¬ 
tions. 

Since Winter in 1885 directed attention to the presence of albumin 
in the urine of patients suffering from this accident, nephritis has been 
regarded as its most common cause, and various writers have reported 
that albuminuria was present in one-half to seven-eighths of their cases. 
Plausibility is lent to the argument by the well-known association of red 
infarcts of the placenta with chronic nephritis, and it has been sug¬ 
gested that similar hemorrhagic lesions occurring in the decidua afford a 
satisfactory explanation for the inauguration of the placental separation. 
Although albuminuria was noted in 11 of the 17 cases mentioned in my 
article, chronic nephritis was present but once. Consequently, I believe 
that the latter is rarely an etiological factor, and that the albuminuria 
should be regarded as an accidental complication, or as a manifestation 
of a toxemic process. 

Bar, Couvelaire, Essen-Moller, Portes and others have observed the 
accident in eclamptic women, and the present tendency is to regard it 
as being due to a toxemic process. Notwithstanding the occasional asso- 






922 


HEMORRHAGE 


ciation with eclampsia, the toxemia is not of the typical preeclamptic 
variety, but is of a special type, concerning whose causation we are as 
yet ignorant. Justification for this belief is afforded by the findings 
in the only examples of concealed hemorrhage which I have examined. 
In these instances, albuminuria and all other symptoms of preeclamptic 
toxemia were absent, yet the intima of the smaller uterine arteries pre¬ 
sented degenerative lesions which could be explained only by the sup¬ 
position that certain toxic substances were circulating in the blood, and 
gave rise to the hemorrhagic changes which characterized the "utero¬ 
placental apoplexy,” which will be described in the following section. 

Multiparity would appear to be a predisposing cause, only 19.2 per 
cent, of the cases collected by Holmes having been noted in primiparae. 
Moreover, the frequency of the accident increases directly with the num- 



Figs. 665, 666. Premature Separation of Placenta with External Hemorrhage 

(Winter). 

ber of pregnancies, and the advocates of the endometritis theory believe 
that these tacts add to the force of their argument. 

Morse in 1918 was able to produce a somewhat similar condition in 
experimental animals by ligating certain uterine vessels or by producing 
torsion of one horn. He therefore attributed to a similar cause the 
lesions about to be described, but to my mind his argument is fallacious, 
foi the reason that torsion of the uterus was not present when the abdo¬ 
men of any oi my patients was opened. Consequently, I believe that his 
experimental lesions are comparable to those with which we are so well 
acquainted following twisting of the pedicle of ovarian tumors. 

Most of the conditions just mentioned may come into play either 
during pregnancy or at the time of labor. On the other hand, certain 
other etiological factors cannot become operative until labor has set in. 
Among these may be mentioned traction exerted by an abnormally short 





PREMATURE SEPARATION OF THE PLACENTA 


923 

umbilical cord, as well as a sudden diminution in the bulk of the uterine 
contents following the birth of the first child in a twin pregnancy or the 
too rapid expulsion of a large amount of amniotic fluid in hydramnios. 

Pathology. Premature separation of the placenta is inaugurated by 
the effusion of blood into the decidua basalis, which then splits, so that 
a thin layer remains in contact with the maternal surface of 'the pla¬ 
centa, while a thicker layer adjoins the muscularis. Consequently, the 
process in its earliest stages consists in the development of a decidual 
hematoma, which leads to compression and ultimate throwing out of 
function of the portion of the placenta adjacent to it. In this, stage "there 
aie no clinical symptoms, and the condition is discovered only upon 
examination of the freshly delivered organ, which will present on its 
maternal surface a sharply circumscribed depression, measuring a few 
centimeters in diameter, and containing dark and partially disorgan¬ 
ized, clotted blood. In most instances the decidual hemorrhage is more 
profuse, so that the area of separation becomes more extensive, and grad¬ 
ually extends to the margin of the placenta. As the uterus is still dis¬ 
tended by the product of conception, it is unable to contract ,and. com¬ 
press the torn vessels in the decidua basalis, and, consequently, the escap¬ 
ing blood makes its way between the membranes and the uterine wall and 
eventually appears externally. Less often, the blood is retained within 
the uterus. This is designated as concealed accidental hemorrhage and 
is liable to occur (1) when there is an effusion of hlood behind the 
placenta, its margins still remaining adherent; (2) when the placenta 
is completely separated, while the membranes retain their attachment 
to the uterine wall; (3) when the blood gains access to the amniotic 
cavity after breaking through the membranes; and (4) when the head 
is so accurately, applied to the lower uterine segment that the blood 
cannot make its way past it. In the majority of such cases, however, 
the membranes are gradually dissected off from the uterine wall, and 
part of the blood eventually escapes from the cervix. 

Formerly, in considering the pathology of the condition, attention 
was centered upon the extent of the separation—partial or complete— 
and whether the hemorrhage was external or concealed. Following the 
observations of Couvelaire, Essen-Moller, myself, and others, it is now 
recognized that in many cases, at least, characteristic lesions occur in 
the uterus, which serve to explain not only the mode of. origin of the 
I separation, but also the failure of the organ to contract after being 
‘emptied of its contents. The uterus, and occasionally the tubes and 
ovaries as well, take on a bluish, purplish coppery coloration and re¬ 
semble an ovarian cyst with a twisted pedicle (Plate NAI). The 
.process may likewise involve one or both broad ligaments, which are then 
gorged with blood. In several instances, in which I performed cesarean 
section, the uterus failed to contract and retract after delivery, and, as 
it remained as soft and flabby as a piece of wet leather, I was forced to 
amputate it supravaginallv. Microscopic examination showed extensive 
intramuscular hemorrhage, which had so dissociated the muscle fibers 
as to destroy completely their contractile properties (Fig. 667). Fur¬ 
thermore, similar hemorrhagic changes in the decidua basalis afforded 




924 


HEMORRHAGE 


a ready explanation for the inauguration of the separation of the 

Couvelaire has designated the condition as uteroplacental apoplexy. 
Its mode of production is not yet clear, but as has already been indi¬ 
cated, it appears to be associated with a toxemic process; and m several 



Fig. 667. —Section through Uterine Wall from a Case of Premature Separation 
of the Normally Implanted Placenta, Showing Dissociation of the Muscle 
Fibers by Hemorrhage. 

Light areas represent muscle, dark areas effused blood. X 40. 

of the uteri which I examined, endarteritic changes and lesions of con¬ 
tinuity in the smaller vessels afforded a satisfactory explanation for the 
production of the intramuscular hemorrhage. It is not yet known 
whether uteroplacental apoplexy is a constant lesion, or is associated 
only with the more serious cases; but the fact that in the four years 
preceding the appearance of my article in 1915, twenty such specimens 







PLATE XVI 



HEMORRHAGIC CHANGES IN UTERUS ASSOCIATED WITH PREMATURE 

SEPARATION OF THE PLACENTA. 














































































V 























































PREMATURE SEPARATION OF THE PLACENTA 


925 


had been described, and that Portes was able to collect 73 cases in 1923, 
makes it apparent that the lesion is not exceptional. 

Occasionally, as described by Knauer and Fraipont, superficial longi¬ 
tudinal fissures develop upon the surface of the uterus. These are 
usually multiple, a few centimeters in length, and extend only a slight 
distance into the muscularis. It is not yet known whether they are due 
to excessive distention of the organ or to the rupture of the superficial 
hemorrhagic areas; but, whatever their mode of production, they occa¬ 
sionally lead to fatal intraperitoneal hemorrhage, as recorded by McNair, 
Oldfield and Shaw. 

Clinical History.—Premature separation of the placenta may occur 
during the later months of pregnancy or at the time of labor. In the 
former case the resulting external or concealed hemorrhage is soon fol¬ 
lowed by the onset of uterine contractions. In either event, if the loss 
of blood is marked, the patient presents signs of acute anemia, and 
passes into a condition of profound shock which may end fatally if 
delivery is not effected promptly. Wright contends that the shock is 
more often the result of traumatism than of actual hemorrhage, and 
may pass off under appropriate medicinal treatment. 

In concealed hemorrhage the uterus gradually becomes of a size con¬ 
siderably larger than would normally correspond to the duration of the 
pregnancy, assumes an almost ligneous consistency, and does not alter¬ 
nate between contraction and relaxation, so that the outlines of the child 
can not be palpated. At the same time the patient complains of 
intense abdominal pain. As the child is dead, auscultation gives nega¬ 
tive results. On the other hand, when the hemorrhage is external, there 
is little or no enlargement of the uterus, and the pain is less severe. 
In the former case the pain and shock are often attributed to other con¬ 
ditions, and the patient sometimes dies before the condition is diagnosti¬ 
cated. 

When the premature separation of the placenta occurs at the time of 
labor as the result of traction upon an abnormally short cord, or of the 
sudden partial emptying of the uterine cavity in twin pregnancy or 
hydramnios, the hemorrhage is usually external, and the foetal heart 
sounds become imperceptible. 

In very exceptional instances the placenta may become separated 
from its attachment during the course of an otherwise normal labor, 
and be extruded in front of the child. No doubt most of the recorded 
cases were really instances of placenta previa, although now and again, 
as in the case reported by Miinchmeyer, such an accident may occur 
even when the placenta is inserted normally prolapse of the pla¬ 
centa 

Diagnosis.— In the absence of external bleeding, the occurrence of 
sharp abdominal pain associated with a uterus of ligneous consistency, 
in a patient in the latter months of pregnancy, is almost pathognomatic 
of concealed accidental hemorrhage, and the diagnosis becomes assured 
when the patient presents signs of acute anemia with manifestations 
of shock While the last-mentioned symptoms may follow the rupture 
of an advanced extra-uterine pregnancy, or the very exceptional spon- 







926 


HEMORRHAGE 


taneous rupture of the uterus, such conditions can be excluded if the 
uterus presents the characteristic board-like consistency. 

When, however, the hemorrhage is external, the diagnosis is rendered 
practically positive by the failure to demonstrate the presence of a 
placenta previa, by vaginal examination, though, of course, it is impos¬ 
sible to differentiate the rare cases of rupture of the circular sinus of the 
placenta to which Budin has directed our attention. When the accident 
occurs during labor and is attended by some loss of blood, the symptoms 
may be suggestive of those following rupture of the uterus, though the 
latter accident rarely occurs except late in an obstructed labor, and is 
not attended by the board-like consistency of the organ. 

In the exceptional instances in which the hemorrhage is entirely 
retroplacental a localized elevation of the corresponding portion of the 
uterine wall can occasionally be detected on palpation. 

Prognosis.—Concealed accidental hemorrhage is one of the most 
serious complications of pregnancy and labor, many of the mothers and 
practically all of the children perishing, Goodell having reported a 
maternal and foetal mortality of 50.9 and 94.4 per cent., respectively. 
Even now the results are not good, as in the 47 radical operations col¬ 
lected by Portes the mortality was 36 and 81 per cent., respectively. 
When the hemorrhage is external, the prognosis is usually dependent 
upon the amount of blood lost; although it should be remembered that 
slight vaginal bleeding does not necessarily preclude the possibility of 
profuse intra-uterine hemorrhage. Furthermore, the mere completion 
of delivery is not synonymous with safety, as a certain proportion of 
patients succumb to atonic postpartum hemorrhage, while others die from 
unrecognized intraperitoneal hemorrhage. 

Treatment.—In the more serious forms the life of the mother can be 
saved only by prompt evacuation of the uterus, as only then can the 
organ contract down and check the bleeding. On the other hand, when 
the separation is partial and the loss of blood but slight, the accident 
may be without serious significance. In the latter class of cases an ex¬ 
pectant treatment should he pursued, and labor allowed to take its 
natural course, interference being indicated only when the symptoms 
become urgent. On the other hand, if the patient presents signs of acute 
hemorrhage, whether of the concealed or external variety, the uterus 
should be emptied with the least possible delay. 

If labor has not yet set in, abdominal cesarean section should be 
performed; and the uterus retained or removed, according as it con¬ 
tracts satisfactorily or remains atonic. The same applies, even if labor 
is already in progress, unless the cervix is partially dilated and so 
softened that manual dilatation can be readily and safely effected, 
following which the child should be delivered by version or forceps, as 
seems advisable. Radical operative treatment is the more justified, for 
the reason that no one can predict to what extent the uterine muscle may 
be disorganized by hemorrhage, so that in many cases only the amputa¬ 
tion of the uterus can prevent death from postpartum hemorrhage. It 
of course goes without saying that the various measures appropriate 



PLACENTA PREVIA 


927 


for combating shock should be employed as adjuvants to the purely 
obstetrical treatment. 

In some instances, following delivery through the natural passages, 
the tonicity of the uterus has been so impaired by the disassociation of 
its fibers by intramuscular hemorrhage that it fails to contract and 
retract during the third stage of labor, and as a result profuse post¬ 
partum hemorrhage may follow. This possibility should always be borne 
in mind, and the operator should have in readiness the necessary ma¬ 
terials for packing the uterus at a moments notice. If, however, bleed¬ 
ing continues in spite of the pack, no time should be wasted in palliative 
expedients, but the abdomen should be opened at once and the uterus 
amputated. In such cases, the outlook is not so promising as if the 
uterus had been removed primarily. 

PLACENTA PREVIA 




It is generally stated that the most common cause of antepartum 
hemorrhage is the partial separation of a placenta implanted in the 
neighborhood of the internal os—placenta previa. 


Fig. 668. Flg ‘ 669 * CENTRAL 

Figs. 668, 669.— Showing Different Modes of Placental Insertion. (Modified 

from American Text-Book.) 


Our knowledge concerning this abnormality may be said to date 
from the end of the seventeenth and the beginning of the eighteenth 
centuries, Portal, in 1685, and Schacher, in 1709, having accurately 
described the condition from a clinical and an anatomical point ot view. 
I Notwithstanding the fact that Smellie, William Hunter, and Rigby were 
! well acquainted with placenta previa and its dangers, very little advance 













928 


HEMORRHAGE 


was made in our knowledge concerning it until Barnes promulgated his 
views as to its mode of production and the methods of controlling the 
hemorrhage arising from it. Since then many investigators have busied 
themselves in determining its etiology and the most suitable treatment. 
An excellent historical resume is contained in the monographs of von 
Herff and Hofmeier. 

In this condition, the placenta, instead of being implanted high 
up upon the anterior or the posterior wall of the uterus, overlaps the 
internal os to a greater or lesser extent, thereby becoming accessible to 
the examining finger. Ordinarily, three varieties are distinguished: 
Placenta previa centralis , lateralis or partialis, and marginalis. In the 
first the internal os is completely covered by placental tissue, which is 
adherent to its margins; in the second the placenta encroaches more 
or less upon the internal os, but does not completely cover it; while in 
the third the placenta is implanted higher up, its lower margin just 



overlapping the internal os (Figs. GG9 and G70). 
Strictly speaking, the differentiation between 


Fig. 670. —Partial Placenta Previa, 
in which No Attempt at Delivery 
Had Been Made (Ahlfeld) 


the several varieties 
should not be 
made until the 
cervix has be¬ 
come fully dilated, 
for the reason that 
the marginal variety 
cannot be felt until 
this has occurred; while 
what may appear to be a 
complete placenta previa 
during pregnancy or the 
first part of labor may prove 
to be only partial, and to en¬ 
croach only slightly beyond the 
margin of the internal os when 
dilatation is complete. In both 
the central and partial varieties, 
partial separation of the pla¬ 
centa is an inevitable conse¬ 
quence of the formation of the 
lower uterine segment and the 
dilatation of the cervix. This is 
always associated with the tear¬ 
ing through of blood vessels, 
which cannot become constricted 
until after the uterus has been 
emptied, so that the resulting 
hemorrhage was appropriately 


designated by Rigby as unavoid¬ 
able. In placenta previa margi¬ 
nalis, on the other hand, hemorrhage does not always occur, and, as 

th< placental tissue can be felt only after dilatation has proceeded to 
















PLACENTA PREVIA 


929 


a cgi tain extent, the existence of the condition is frequently unrecog¬ 
nized. Such cases are closely related to the so-called vicious insertion 
of the placenta described by Pinard and his pupils, which is of frequent 
occurrence. 

Frequency. Placenta previa is fortunately a comparatively rare com¬ 
plication, although the statements as to its frequency vary considerably. 
Ihus, W. Muller, whose statistics were based upon 876,432 labors, stated 
that it occurs once in 1,078 cases * while Lomer, Tarnier, and Burger 
and Graf, on the other hand, estimated its incidence as once in 723, 
207, and 130 labors respectively. In all probability it would be cor¬ 
rect to say that it is met with about once in 1,000 cases in private, as 
compared with once in 250 cases in hospital practice. 

Moreover, there is considerable variation in the statements concerning 
the relative incidence of the several varieties, though it is generally ad¬ 
mitted that the partial form is the most frequent. Thus, Koblanck, 
Strassmann, and Burger and Graf observed the central variety in 18.4, 
23.8, and 18.4 per cent., the partial in 64.5, 61.5 and 36 per cent., and 
the marginal in 17.1, 15.2, and 45.6 per cent, of their placenta previa 
cases respectively. Pinard, on the other hand, states that he has never 
met with a placenta which was uniformly adherent to the margins of 
the internal os, and that the marginal is the most frequent variety. In 
favor of this view he adduces the fact that he had observed the so-called 
vicious insertion in 28.12 per cent, of all normal labors. His conclusions 
must, however, be accepted with reserve, since they are based upon the 
measurement of the distance of the margin of the placenta from the 
point of rupture of the membranes, as determined from the examination 
of the after-birth, and it is clear that such a mode of investigation is 
not beyond reproach. 

Etiology.—Concerning the etiology of placenta previa comparatively 
little is known. Two factors, however, appear to favor its occurrence— 
multiparity and endometritis. 

The abnormality occurs comparatively rarely in primiparae, and in¬ 
creases in frequency with the number of children which the individual 
has borne. This point is strikingly illustrated by the following figures 
of Doranth, which are based upon 30,796 labors occurring in Chrobak’s 
clinic. In these the incidence of placenta previa was 0.17, 0.48, 1.37, 
1.28, 3.39, and 5.51 per cent., according as the patients had given birth 
to 1, 2, 3, 4, 5, 6, or 7 or more children respectively. 

The occurrence of placenta previa is not only favored by the absolute 
number of children, but also by the rapidity with which the labors have 
followed one another, Strassmann finding that the average age of his 
patients was 32.9 years, and that the average number of labors was 6.38. 
In 55 multiparous women with placenta previa in our service it was 
found that they had averaged 5.9 children each in the ten years follow¬ 
ing the first delivery. 

Strassmann also pointed out that one of the most important factors 
in its development was to be found in defective vascularization of the 
decidua, the result of inflammatory or atrophic changes, the latter being 
favored by repeated and closely following pregnancies. Such conditions, 


930 


HEMORRHAGE 


>v 


he maintained, limit the amount of blood going to the placenta, so that 
in order to obtain its requisite supply of nutriment it becomes necessary 
for it to spread over a greater area of attachment, and in so doing its 
lower portion occasionally approaches the region of the internal os, 
completely or partially overlapping it as the case may be. Plausibility 

is lent to such a view by 
the fact that the placenta 
in this abnormality is at¬ 
tached over a greater area 
of the uterus than usual, 
while at the same time it 
is often considerably thin¬ 
ner. Thus, in one of my 
cases which came to au¬ 
topsy, the placenta was 
almost membranous, and 
its site occupied four-fifths 
of the interior of the 
uterus. 

The older authorities 
believed that placenta 
previa was due to the 
separation from its attach¬ 
ment of a normally im¬ 
planted ovum, which, fall¬ 
ing to the lower portion 
of the uterus, subsequently 
contracted new connections 
instead of escaping 
through the cervix. Later 
it was urged that such a 
view failed to explain the 
production of the central 
variety, as it was incon¬ 
ceivable that the escape of 
the minute ovum from the 
uterus could be delayed sufficiently long to permit the formation of 
attachments in the neighborhood of the internal os. The fallacy of this 
view is apparent when one recalls the fact that the uterus at the time of 

conception is normally so anteflexed that the region of the internal os 

is at a higher level than the fundus, hence the force of gravity would 
not necessarily aid in carrying the ovum towards the cervix. Further¬ 
more, Bumm contended that, in view of the congested condition of its 
margins, the internal os is smaller than the fertilized ovum. 

The gravitation theory was generally accepted until 1888, when 
Hofmeier and Kaltenbach advanced the theory that a part of the pla¬ 
centa developed from a portion of chorion in contact with the decidua 
reflexa. As pregnancy advanced this so-called reflexa placenta gradually 
bridged over the internal os and eventually came in contact and fused 



Fig. 671 . —Right Half of Uterus with Central 
Placenta Previa and Velamentous Insertion 
of Cord. Note the Cup-like Form of the Pla¬ 
centa and its Varying Thickness. X 2 /s- 








PLACENTA PREVIA 


931 


Serotina 


with the decidua vera, after which vascular connections with the uterine 
wail became established (Fig. 673). 

This view at once met with very favorable consideration, and Jolly, 
in 1911, advanced incontrovertible proof of its correctness in many 
cases. When Hofmeier advocated this mode of origin at the 1897 meet¬ 
ing of the German Gynecological Congress, he was careful to state that 
it was not the only manner in which a placenta previa might originate; 
inasmuch as in certain instances the extension of the placental area 

might be effected by a process 
cleavage in the decidua vera, 
the result of which the 
margin of the organ would ex¬ 
tend beyond the serotina. 
Should such cleavage extend 
downward, it was readily con¬ 
ceivable that the placenta 
might grow on either side of 
the internal os, 
a n d, eventually, 
completely cover 
it. At that time 
correct informa- 
t i o n concerning 
the mode of im¬ 
plantation of the 
ovum and of the 
growth of the placenta were not 
available, and Hofmeier was 
not aware that an analogous 
process occurs in every normal 
pregnancy. 

In view, therefore, of our 
present knowledge concerning 
the normal implantation of the 
ovum, as well as of Strassmann’s theoretical deductions, it appears prob¬ 
able that placenta previa results either from the primary implantation of 
the ovum in the lower portion of the uterus, associated with such exten¬ 
sive cleavage of the decidua vera that the extension of the placenta to the 
region of the internal os is facilitated, or it result from the development 
of a part of the placenta upon the internal surface of the dechlua vera. 

Very exceptionally, as reported by von Weiss, Politick, Kermauner, 
and Labhardt, a part of the placenta is developed upon the upper portion 
of the cervix. The possibility of such an occurrence must be admitted, 
although Ahlfeld and Aschoff have shown that it is more apparent than 
real, as it is not due to a primary implantation, but rather to a secondary 
cleavage of the cervix by the extension of a placenta which had been 
primarily implanted above it. 

Symptoms.—The most characteristic symptom of placenta previa is 
hemorrhage, which usually does not appear until after the seventh month 



Reflexa 


Fig. 672 . —Diagram Illustrating Hofmeier’s 
Theory of the Formation of Placenta 
Previa. 












932 


HEMORRHAGE 


of pregnancy. At the same time it is probable that many abortions are 
due to this abnormality, although the true state of affairs usually 
escapes observation. I have seen several abortions in the third month 
which were clearly due to it. 

The hemorrhage frequently comes on without warning in a pregnant 
woman who had previously considered herself in perfect health. Occa¬ 
sionally it makes its first appearance 
while the patient is asleep, so that on 
awakening and feeling the bedclothes 
moist, she is surprised to find that she 
is lying in a pool of blood. Ordinarily, 
the initial bleeding ceases spontaneously, 
to recur again when least expected, 
though the first hemorrhage is rarely so 
profuse as to prove fatal. In other 



cases the bleeding does not cease en¬ 


tirely, there being a continuous dis¬ 
charge of small quantities of blood¬ 
stained fluid, which eventually so 
weakens the woman that a comparatively 
slight acute hemorrhage may be suffi¬ 
cient to cause death. In a certain pro¬ 
portion of cases, particularly when the 
insertion is marginal, the bleeding does 
not appear until the time of labor, when 
it may vary from a slight, blood-stained 
discharge to a profuse or even fatal 
hemorrhage. As a rule, it is less copious 
in this than in the other varieties. 

The mode of production of the 
hemorrhage is readily understood when 
one recalls the changes which take place 
in the later weeks of pregnancy and at 
the time of labor. When the placenta 
is inserted centrally or partially, it is 
Wall of Uterus Showing "par- evident, that as the formation of the 

tial Placenta Previa. Note the lower uterine segment and the dilatation 
area of separation just above in- ^ • , i , , , 

ternal os, which was sufficient to 0± the lllternal OS progress its attach- 
cause fatal hemorrhage, x ments must inevitably be torn through, 

the rupture being necessarily followed 
by a hemorrhage from the maternal vessels. Furthermore, the bleeding 
is favored by the fact that it is impossible for the stretched fibers of 1 
the lower uterine segment to compress the torn vessels, as is the case 
w hen the normally implanted placenta becomes separated during the 
thiid stage of labor. Moreover, when the placenta has developed in 
the eapsularis, it is apparent that the thin tissue is devoid of all support 
where it bridges over the region of the internal os, and consequently a 
slight trauma will open up the intervillous space. 

As the placenta previa occupies the lower portion of the uterine 


Fig. 673 . — Sagittal Section 
through Cervix and Posterior 









PLACENTA PREVIA 


933 


cavity, it interferes with the accommodation of the foetal head, and 
^consequently abnormal presentations are unusually frequent, Muller 
having noted 272 transverse and 107 breech presentations in 1,148 cases, 
j I n normal labor all danger is ordinarily past with the completion of 
the second stage. In placenta previa, on the other hand, as a result of 
. abnormal adhesions or an excessively large area of attachment, the 
process of separation is sometimes interfered with, so that profuse hemor¬ 
rhage frequently occurs after the birth of the child, and exceptionally 
continues even after the manual removal of the placenta. In other cases 
hemorrhage is due to the fact that the overstretched lower segment, 
which normally retracts but poorly, is unable to compress the vessels 
traversing its walls. 

Diagnosis.— In patients suffering from uterine hemorrhage during 
the last third of pregnancy, placenta previa or the premature separa¬ 
tion of the normally implanted placenta should always be suspected, and 
the possibility of the existence of the former should not be dismissed 
until careful examination has demonstrated its absence, in which event 
the latter condition should be diagnosticated. In the great majority 
of cases of placenta previa the cervix is softer and more succulent than 
usual, and its canal more patulous, so that but little difficulty is ex¬ 
perienced in carrying the finger through the internal os and feeling 
the characteristic spongelike placental tissue, or at least making out 
a soggy, thick substance lying between the finger and the presenting 
part. When, however, the cervix is not patulous it should be dilated, 
under anesthesia if necessary, sufficiently to permit the introduction of 
the finger, which is then passed through the internal os and swept 
around the adjacent portion of the low'er uterine segment, when the 
presence or absence of the abnormality can be positively determined. It 
is true that such a procedure occasionally results in the induction of 
premature labor; but the risk is justifiable, since we possess no other 
means of arriving at a definite diagnosis, which should be made at any 
(cost on account of the very serious menace which the existence of the con¬ 
dition offers to the life of the patient. 

Prognosis.— The prognosis is always serious. According to Muller, 
under expectant treatment the maternal mortality varied from 36 to 40 
per cent., while for the children it was about 66 per cent., one half of 
those which were born alive perishing within the first ten days following 
delivery. The danger to the mother arises primarily from hemorrhage, 
which 'is usually the direct result of the condition, though frequently 
it may be increased by deep cervical tears resulting fiom too hasty 
artificial dilatation, or from the extraction of the child through an imper¬ 
fectly dilated cervix. Moreover, such patients are particularly prone to 
puerperal infection, which is favored by the piesence of the thrombosed 

sinuses in the lower uterine segment. 

The foetal mortality is due in great, part to the fact that the acci¬ 
dent so frequently comes on while the children are quite premature. In 
other instances they perish from asphyxiation, the result of placental 
hemorrhage, occasionally succumbing during attempts at exti action 
through an imperfectly dilated ceivix. 







934 


HEMORRHAGE 



Nowadays the maternal mortality depends upon the vaiiety of the 
placenta previa, the method of delivery, and the condition of the patient 
when first seen. Thus, in 178 cases reported by Hofmeier, Behm, and 
Lomer, and treated by 11 different obstetricians by Braxton Hicks’s 
method of combined version, the maternal mortality was 4.5 per cent. 
Jellett has reported a death rate of 3.69 per cent, in 138 cases treated 
at the Rotunda in Dublin, and Essen-Moller on of 3.7 per cent, in 132 

cases. Pinard lost four mothers in 183 cases 
and Stratz one out of 110 patients whom 
he delivered personally. Kronig and Sell- 
heim, on the other hand, report that 8 to 
10 per cent, of the patients die from hemor¬ 
rhage, if not treated by cesarean section. 

In hospital practice, where many patients 
are admitted after inefficient treatment by 
poorly trained practitioners, puerperal in¬ 
fection plays a large part in the production 
of maternal mortality. Thus, 40 per cent, 
of the deaths reported by Burger and Graf 
were attributable to infection; while in Bar’s 
series 71 per cent, were due to the same 
cause. The prognosis is much more serious 
in central placenta previa than in the other 
varieties. Furthermore, the mortality de¬ 
pends upon the condition of the patient 
when first seen, if being evident that women 
who have suffered from profuse and repeated 
bleeding have far less chance of recovery 
than those who come under observation after 
the first slight hemorrhage. 

Unfortunately, the foetal mortality has 
shown comparatively little decrease in recent 
years, Kiistner, Burger and Graf, and Strass- 
mann giving percentages of 35, 55, and 
61.22 respectively. A very great improve¬ 
ment in this respect is hardly to be antici¬ 
pated on account of the large number of 
premature children with which one has to 
deal, as Thompson’s analysis of our material 
showed that the proportion between pre¬ 
mature and mature children was as 8 to 1. 
Treatment.—On account of the danger of profuse and unexpected 
hemorrhage, pregnancy or labor, as the case may be, should be termi¬ 
nated in the most conservative manner as soon as possible after a pla¬ 
centa previa has been positively diagnosed. There is no single method 
of treatment applicable to all classes, and the obstetrician who under¬ 
stands how to differentiate his cases will obtain the best results. 

If the diagnosis is made during pregnancy, and the cervix is suffi¬ 
ciently dilated to permit the introduction of two fingers, treatment will 


Fig. 674 . —Fcetus Partially 
Extracted from a Patient 
Dying of Placenta Pre¬ 
via, Showing how It Acts 
as a Tampon (Leopold). 







PLACENTA PREVIA 


935 


depend upon whether the child is viable or not. In the former case 
almost ideal results are obtained by the introduction of a Champetier de 



Nasal SVpUjit, _ 


• Suprarenal GI. 
. ■ Rt Kidney 


-SpinalCenai 


Scrotum 


-- Os Ilium 


Uterus ... 


Left Hand at 
Wrist 

Place at a 
Sternum - 

Umbilical 
• Cord 


1 rache 


,'vfcsoOfuatJys 


Spinal c« ai 


- Thyroid 


Right Lung 

Cardiac 

Impression 

Diaphragm . 


Right Foot at 
Ankle 


- -RtM, Paces' 
_Placenta 


Sigmoid Flexure- .... 


Ap5u ot Piacental 
Separation * 

Internal Os . 


Left Leg Drawn Down in 
Braxton Hiche Vemior 


External 


- Liver 


... L.M.Gluteus 


_.. Aix.a of Plfxx-utui 
Separat ion 


Fig. 675 . _Left Half of Frozen Section through Uterus with Central 

Placenta Previa, Showing the Effect of Version. (Titus.) X / 2 - 


Bibes balloon after rupture of the membranes or perforation of the 
placenta, according as one has to deal with a partial or central insertion, 
dilatation being hastened by attaching a 2-pound weight to the end of 







936 


HEMORRHAGE 


the tube by a string and suspending it over the foot of the bed. After 
the expulsion of the bag. the child should be delivered by version and 
extraction. On the other hand, if the child is not viable, equally good 
maternal results are more readily obtained by bringing down a foot by 
Braxton Hicks's maneuver and using the breech of the child as a tampon 
to control further bleeding. If the hemorrhage ceases after the foot has 
been brought down, the expulsion of the child may be left to Nature; 
but if the oozing continues, gentle traction should be made upon the leg 
so as to compress the placenta with the child's buttocks. Whichever 
method is employed, extraction should not be attempted until the cervix 
is completely dilated, or at least sufficiently so as to permit the ready 
passage of the head. Too great haste is liable to cause deep cervical 
tears, giving rise to additional hemorrhage and requiring the application 
of sutures, while in other instances serious difficulty may be encountered 
in delivering the child. 

Generally speaking, better results will be obtained in private practice 

by the employment of Braxton Hick's bipolar 
version, no matter what may be the condition 
of the child, for the reason that the average 
practitioner will rarely be equipped with a 
suitable balloon and the necessary para¬ 
phernalia for its introduction. In hospital 
practice, however, its employment has un¬ 
doubtedly aided materially in diminishing 
the foetal mortality, and Thompson states 
that in 36 consecutive cases so treated in our 
service there was no maternal mortality. 

In very exceptional instances in primi- 
parous women the cervix may be so rigid 
that it is impossible to dilate it sufficiently 
to permit the employment of either of the 
above-mentioned procedures. In such cir¬ 
cumstances, in the hands of an expert sur¬ 
geon, cesarean section may be indicated, but 
in general practice a tight cervical and vagi¬ 
nal pack of sterilized gauze bandage should 
be applied. After remaining in place for a 

Fig. 675. The mecJian "aspect few h° urs this will usually bring about 
of the half of foetus to left of sufficient dilatation to permit the employ- 

trorfi r»Q 1 limn l a ^... A 1 J 



Fig. 676.— Sketch to Elucidate 


vertical line is shown in the j r i , , 

frozen section. ment of whatever maneuvers may be deemed 


necessary. The use of the pack, however, 
should be restricted as iar as possible, and should be regarded merely 
as a temporary expedient, partly because it may give rise to a false 
sense of security, but particularly on account of the danger of infection. 

At the time of labor the treatment depends upon the degree of dila¬ 
tation and the condition of the patient. If the cervix is fully dilated, 
immediate delivery by version or forceps is indicated. On the other 
hand, if the dilatation is only partial, and the placenta is inserted 
maiginally, good results very frequently follow rupture of the mem- 







PLACENTA PREVIA 


937 


branes, since the placenta is then able to follow the retracting uterine 
wall. In all other cases, provided the child is alive, I prefer to complete 
the dilatation by means of a large Champetier de Ribes balloon, which 
should be introduced into the amniotic cavity after rupturing the mem¬ 
branes or perforating the placenta, as the case may be. Dilatation is 
hastened by gentle traction exerted by the hand or by a weight attached 
to the end of the tube, and after extrusion of the bag delivery is usually 
best effected by version and extraction. If, however, a balloon is not 
available, equally satisfactory maternal results may be obtained by 
Braxton Hicks’s method of bipolar version, provided extraction is not 
attempted until the cervix is fully dilated. 

The practitioner is earnestly warned against the employment of rapid 
manual or instrumental dilatation of the cervix. In this class of cases 
it is particularly prone to laceration, and, no matter how gradually and 
carefully the dilatation may lie effected, deep tears frequently result. 
These may extend far out into the base of the broad ligament or up 
into the lower uterine segment, and occasionally entirely through the 
uterine wall. I recall one of my own cases in which death resulted from 
a large broad ligament hematoma following a tear through the lower 
uterine segment, which I thought had been satisfactorily repaired, as 
well as several consultation cases in which laparotomy and amputation 
of the uterus were necessary to check intraperitoneal hemorrhage follow¬ 
ing extension of cervical tears. 

As already indicated, all danger has not passed with the delivery of 
the child, and great care should be exercised in the conduct of the third 
stage of labor. If there is no hemorrhage, expression should not be 
attempted until the placenta has been expelled into the vagina; but if 
bleeding is profuse, Crede’s method of expression should be immediately 
resorted to, and, if not effective, the placenta should be removed manually. 
If the loss of blood continues after the completion of the third stage, 
the cervix should be inspected, and immediately repaired if lacerated; 
but if no lesions are present, an intra-uterine pack should be introduced, 
so as to exert compression upon the flabby lower uterine segment. 

Whenever the hemorrhage has been profuse, and the patient presents 
the subjective symptoms of an acute anemia, one should resort to 
the therapeutic measure outlined under the treatment of post¬ 
partum hemorrhage. Occasionally, when the patient is markedly ex¬ 
sanguinated when first seen, but is losing little or no blood at the time, 
it is better to transfuse her before beginning any obstetrical manipu¬ 
lation. 

In view of the danger to the mother, but particularly because many 
children are sacrificed by extraction through an imperfectly dilated 
cervix, Tait, Palmer Dudley, and others recommended the performance 
of cesarean section, provided the child is viable and the patient in good 
condition. Ten years later, in 1908, Kronig and Sellheim stated that 
8 to 10 per cent, of all placenta previa patients die from hemorrhage, 
and held that our methods of treatment were in urgent need of improve¬ 
ment. Furthermore, as they believed that any method associated with 
natural or artificial dilatation of the lower uterine segment still further 






938 


HEMORRHAGE 


agumented the danger, they advocated that all cases of partial or central 
previa should be treated by classical or extraperitoneal cesarean section, 
after which the lower uterine segment should be tightly packed w r ith 
iodoform gauze. Their proposal was accepted by many operators, but 
called forth severe criticism on the part of more conservative obstetricians 
and has given rise to a voluminous literature. 

When we remember that Jellet in 1910, and Essen-Moller in 1921, 
reported a maternal mortality from all causes of 3.69 and 3.7 per cent., 
respectively, and that Stratz lost only one of 110 personal cases, it is 
apparent that our German confreres have either greatly over-estimated 
the dangers of the condition, or had treated their patients badly prior 
to the employment of radical measures. This being the case, it seems 
doubtful whether trained and conservative obstetricians will endorse 
the extensive use of cesarean section, and I consider that its compara¬ 
tively frequent employment in this country affords proof of the poor 
obstetrical training which our practitioners have received. Furthermore, 
its employment by any but expert operators will lead to a higher death 
rate than is obtained by the usual methods, and even in their hands 
it does not always give ideal results. For example, Stoeckel, who ad¬ 
vocates cesarean section, whenever as much as four centimeters of the 
internal os is covered by placental tissue and the patient is uninfected 
and the child viable, reports a mortality of 9.7 per cent, following it. 

For these reasons, I believe that the skillful obstetrican will rarely 
need to resort to cesarean section except under two conditions—first, 
in the very rare case of a primipara whose cervix is too rigid to permit 
the introduction of a balloon, and second in cases of complete placenta 
previa in women nearing the end of the childbearing period, who are 
especially desirous of a living child. Furthermore, I am prepared to 
admit that in many instances cesarean section done by a competent 
general surgeon will give better results than obstetrical treatment in 
unskilled hands, but that is not ideal obstetrics. Thus far, but two 
cesarean sections have been done in our service for placenta previa, and, 
as the results following the employment of the balloon have been extra¬ 
ordinarily satisfactory, I do not anticipate extending the employment 
of the former operation. 

The argument that wider use of cesarean section will increase the 
number of children born alive is plausible and attractive, but it should 
always be remembered that % the majority of the children concerned are 
premature, so that even if they are delivered alive their chances for 
prolonged existence are not great, and consequently it seems the reverse 
of conservatism to expose the mothers to any additional risk on their 
account. 


POSTPARTUM HEMORRHAGE 

With the exception of the very rare cases incident to inversion of the 
uterus, a serious bleeding following the birth of the child is usually due 
to one of three causes. Of these the most common is defective function¬ 
ing of the uterine musculature or atony; less frequently it is due to re- 




POSTPARTUM HEMORRHAGE 


939 


tention of the partially separated placenta or of individual cotyledons; 
while occasionally it results from deep tears involving the tissues of the 
birth canal. 

Etiology.—As long as the placenta remains firmly attached to the 
uterine wall there can be no possibility of hemorrhage, but when it has 
become partially separated, the normal action of the uterine musculature 
is interfered with. As a result the torn vessels at the partially denuded 
placental site are imperfectly constricted, and more or less profuse hemor¬ 
rhage occurs. Incomplete separation of the placenta may be attributed 
to improper management of the third stage of labor, particularly the too 
early and energetic employment of Crede’s maneuver. Exceptionally, it 
may result from an abnormally intimate attachment of the placenta, 
due to defective development of the decidua, or some other morbid con¬ 
dition. The retention of isolated cotvledons or of a small succenturiate 
lobe interferes with the normal contraction and retraction of the uterus 
in precisely the same manner as the partially separated placenta. 

The part played by deep tears of the generative tract is obvious, and 
will be considered in detail in the following chapter. 

In very rare instances serious hemorrhage may result from rupture of 
large varicose veins, of an aneurysm of the uterine artery, or the dis¬ 
turbance of areas of thrombosis in the cervix. 

Formerly, I held that atony of the puerperal uterus was a relatively 
infrequent cause of postpartum hemorrhage, but more prolonged ex¬ 
perience has convinced me that I was in error, and I now regard it as the 
most usual cause. This belief is based upon the fact that in most 
cases of moderate hemorrhage I have found no evidence of retention 
of placental tissue nor of tears, and the bleeding has persisted until 
vigorous contraction of the uterus was induced, when it ceased, never 
to return. 

The cause of such defective functioning of the uterine musculature 
is not known, but the condition is seldom primary; for, with the ex¬ 
ception of the instances in which it follows excessive distention of the 
uterus incident to twin pregnancy or hydramnios, serious abnormalities 
are often associated with some mechanical cause, such as retention of 
portions of the placenta, the presence of myomata, or in rare cases the 
existence of adhesions between the uterus and the surrounding organs. 
Occasionally atony may be associated with degeneration of the muscle 
fibers resulting from an abnormal invasion of foetal elements, as de¬ 
scribed by Kworostansky, Martin, and others. Moreover, the occasional 
Instances in which patients bleed profusely after each labor without 
demonstrable cause likewise afford corroborative evidence. In a number 
of such cases Labhardt believes that he has been able to demonstrate the 
presence of an excessive amount of connective tissue between and within 
the muscle bundles. In view of our experience, it is certain that Veit 
i went too far in denying in toto the possibility of a primary atony 

The rare cases of hemorrhage following paralysis at the placental site, 
in which the rest of the organ remains firmly contracted, as in the cases 
reported by Chiari, Braun and Spaeth, Olshausen, and others, point to 

the possibility of a partial atony. 


940 


HEMORRHAGE 




Clinical History. —The loss of 600 or more cubic centimeters of blood 
was noted during and immediately following the third stage of labor in 
13 per cent, of one thousand consecutive normal labors which I studied, 
while a loss of 1,500 or more cubic centimeters was observed about once 
in every one hundred labors, but with proper treatment a fatal issue 
should occur only once in 2,000 or 2,500 patients. Excessive bleeding 
may supervene either during or after the third stage of labor. In the 
first class of cases, as a rule, it is the result of tears or of partial 
separation of the placenta. Fortunately, hemorrhage dependent upon 
the latter cause is usually not serious, for the reason that the condition 
is only transitory, and ceases when complete separation has occurred, 
following which satisfactory uterine retraction checks the loss of blood. 
Exceptionally the bleeding may persist even after the placenta has be¬ 
come completely separated and lies free in the uterine cavity. In such 
cases it is due either to tears or to imperfect functioning of the uterus. 

Generally speaking, partial separation occurring during the course of 
placental expulsion by the Schultze mechanism is not accompanied by 
external hemorrhage until the placenta escapes from the vulva, when the 
large amount of blood collected behind it is suddenly discharged. In 
Duncan’s mechanism, on the other hand, the loss of blood continues 
throughout the entire placental period. 

A hemorrhage which persists after the extrusion of the placenta may 
be due to -tears, retention of placental remnants, or to atony. In the 
first there is a steady flow of bright-red blood, which begins immediately 
after the delivery of the child. When due to retained placental tissue, 
the blood escapes in gushes, which are apt to be synchronous with the 
uterine contractions, and is frequently in large clots; whereas in cases 
due to primary atony there is a continuous flow of blood, which may be 
so abundant as to cause death within a very few minutes. In rare in¬ 
stances the hemorrhage may be concealed several liters of blood some¬ 
times accumulating in the uterine cavity. 

The amount of blood lost during a postpartum hemorrhage may vary 
from 600 to 3,500 cubic centimeters, the latter extreme, however, being 
invariably incompatible with life, although upon several occasions I have 
seen recovery follow a loss of 2,500 cubic centimeters, and once after a 
measured loss of three liters. Generally speaking, the woman in labor 
can bear with comparative impunity the loss of an amount of blood 
which would seriously endanger the life of a well-developed man. This 
is attributed by Zuntz to the fact that a considerable increase in the 
amount of blood occurs during pregnancy, which has been confirmed 
by the as yet unpublished observations of Harris in our service. In any 
event, the effect of hemorrhage will depend more upon the general con¬ 
dition of the patient than upon the actual quantity lost. Thus, a 
woman who is already exhausted by a prolonged labor or weakened by 
antecedent disease may succumb after a loss of from 1,000 to 1,500 
cubic centimeters, which others bear with impunity, but generally speak- 
ing the a\erage woman can bear a loss of two liters without serious 
consequences. As a rule, the loss of a moderate amount of blood is 
not attended by serious symptoms; but when the hemorrhage is profuse 





POSTPARTUM HEMORRHAGE 


941 


the pulse becomes rapid and compressible, the face becomes pallid and 
assumes a drawn appearance, while at the same time the woman may 
complain of disturbed vision, chilliness, and shortness of breath. In 
extreme cases symptoms of air hunger appear, and the patient usually 
passes into unconsciousness before the fatal termination. 

Diagnosis. The diagnosis offers no difficulty, except in the rare in¬ 
stances in which the hemorrhage has taken place into the uterine cavity 
and does not appear externally. It must, however, be distinctly stated 
that concealed hemorrhage should never occur if the condition of the 
uterus is conscientiously watched, although, if routine precautions are 
neglected, the first indication of the condition may be afforded by the 
pale and haggard appearance of the patient. On examination the pulse- 
rate will be found greatly accelerated, the uterus greatly increased in 
pize, and presenting a doughy consistence, instead of the characteristic 
firm, hard sensation offered by the normal puerperal organ. Pressure 
upon it is followed by a copious flow of blood from the vagina. 

As the decision concerning the proper treatment of the patient gen¬ 
erally depends upon the recognition of the source of the hemorrhage, a 
differential diagnosis is of the utmost importance. Generally speaking, 
if the bleeding commences immediately after the birth of the child, it is 
due either to tears of the genital tract or to partial separation of the 
placenta. In the latter case it usually ceases temporarily after energetic 
kneading of the uterus, but recurs as soon as it is allowed to relax. If 
such manipulations prove of no avail, it is probable that the hemorrhage 
comes from a tear, although this is not a universal rule, since in a certain 
number of instances the loss of blood will continue until the placenta is 
expressed by Crede’s method or is removed manually. 

Again, a hemorrhage persisting after the uterus has been emptied, 
while abdominal palpation shows that the organ itself is firmly con¬ 
tracted, suggests an extensive tear of the birth canal, which should be 
sought for, and closed with sutures when found. In order to accomplish 
this, the patient having been brought to the edge of the bed, the external 
genitalia are carefully inspected. If the perineum is intact, the cervix 
should be forced down toward the vulva by pressure upon the fundus, 
and if this fails to bring it into view, it should be exposed by means 
of a speculum and tenaculum forceps. If a cervical lesion cannot be 
detected, the vaginal walls should be spread apart by means of a speculum 
and thoroughly inspected. A hemorrhage which does not come on 
until ten or fifteen minutes after the birth of the child can hardly be 
due to this cause. 

On the other hand, if the uterus does not contract and retract firmly 
after the expulsion of the placenta, or if it remains so only so long as 
kneading is kept up, the cause of the hemorrhage must be sought for 
either in atony or in the retention of a placental cotyledon. Certainty 
with regard to the latter point is usually obtained by careful inspection 
of the after-birth, which should be made a matter of routine, a large 
defect upon its maternal surface indicating the retention of a cotyledon, 
while a more or less circular defect in the membranes a short distance 
from the placental margin shows that a succenturiate lobe has been left 


942 


HEMORRHAGE 


behind. At the same time one should he careful not to confound mere 
fissures with defects due to loss of tissue. The diagnosis of primary 
atony should be made only after every other explanation has been 
excluded. 

Treatment.— With proper management, serious hemorrhage during 
and directly following the third stage of labor should be extremely 
rare. The most important prophylactic measures consist in watching the 
condition of the uterus after the birth of the child, and not resorting to 
Crede’s maneuver until the rising up of the fundus indicates that the 
placenta has become completely detached. Premature attempts at ex¬ 
pression are a frequent cause of imperfect separation. Again, owing to 
the tendency toward relaxation following the birth of twins, as well as 
in hydramnios, concealed hemorrhage, and placenta previa, the condition 
of the uterus in such cases should be most carefully watched for the 
few minutes immediately following the birth of the child, and energetic 
kneading through the abdominal walls promptly resorted to upon the 
first sign of fading contraction. 

If examination of the placenta immediately after its expulsion re¬ 
veals any serious defect, immediate preparations should be made for the 
removal of the retained portion, whether symptoms supervene or not. 

In the presence of actual hemorrhage, the treatment varies according 
as the placenta is still within the uterus or has already been expelled. 
In the former case the uterus should at once be grasped through the 
abdominal wall and firmlv kneaded. If firm contractions come on, all 
is well, but if the hemorrhage continues and the uterus relaxes as soon 
as the kneading is stopped, the placenta should be expressed by Crede’s 
method; and if this cannot be accomplished and the patient’s condition 
is alarming, it should be removed manually, when the directions given in 
Chapter XXIV should be conscientiously followed. 

If the hemorrhage does not cease after the delivery of the placenta, 
the cause should be ascertained and suitable treatment instituted. Tears 
should be located and their edges brought together by sutures. On the 
other hand, if the hemorrhage is the result of the retention of placental 
tissue, the gloved and disinfected hand should be carried up into the 
uterus in order to seek for and remove the retained cotyledon. In such 
circumstances the hand acts as a most efficient irritator, causing the 
uterus to contract energetically. After separating the retained portion 
of placenta, the hand should not be withdrawn at once, but should be 
allowed to recede gradually, as it is forced down by the contraction of 
the fundus. 

Ik the hemorrhage is due to atony, the uterus should be vigorously 
kneaded, and 1 cubic centimeter of pituitary extract followed by 30 
minims of the fluid extract of ergot administered hypodermically. 
After careful disinfection of the skin, the needle should be plunged deep 
down into the tissues of the thigh, at right angles to the surface, since 
in this way the chances of abscess formation are greatly diminished. 
In my experience, pituitary extract acts within three minutes, but its 
effect is much more transient than that of ergot. Consequently, it is 





POSTPARTUM HEMORRHAGE 


943 


advisable to administer the former first, and to follow it by the latter if 
prolonged stimulation of the uterus is needed. 

If these measuies are not attended with the desired result a very hot 
intra-uteiine douche of several liters of sterile salt solution should be 
given. This usually acts as a most efficient hemostatic, effectively irri¬ 
tating the uterus and causing it to contract forcibly and permanently. 

If the hemoirhage persists in spite of the douche, our only hope of 
controlling it is by packing the uterus tightly with sterile gauze, which 
should be introduced according to the directions given in Chapter 
XXIV. Before resorting to the use of the pack it is always advisable 
to palpate the interior of the uterus, as occasionally a portion of the 
placenta may have been retained, even though immediately after expul¬ 
sion the organ may have apparently been entire. 

Fieux has pointed out that postpartum hemorrhage is usually venous 
in character and occurs under very low pressure. Accordingly he states 
that placing the patient in the Trendelenburg posture, which can be 
improvised by adjusting the back of a chair under the mattress, over¬ 
comes the pressure and checks the bleeding. I have had no experience 
with the method, but he states that its results are sometimes marvelous. 

Should the loss of blood continue after the employment of these 
measures the aorta may be compressed by means of a stout rubber tube 
tied about the patient’s waist, as recommended by Momburg. This 
emergency measure has been extensively employed in Germany, but has 
not found favor elsewhere. 

Occasionally in postpartum hemorrhage due to atony following pre¬ 
mature separation of the placenta, or placenta previa, slow bleeding will 
persist in spite of all these measures. In such circumstances, if the 
patient is in a hospital, life may be saved by opening the abdomen and 
removing the uterus. 

Formerly it was customary to recommend the introduction into the 
uterus of ice, or of solutions containing vinegar, the perchlorid of iron, or 
other astringent substances. Their employment, however, is not advis¬ 
able, since ice and ordinary vinegar are never sterile, while the iron 
solution accomplishes its purpose by the formation of dense coagula, 
which are later separated from the uterus by suppurative processes. 
Above all, none of them acts as promptly or efficiently as the pack, the 
employment of which, although comparatively rarely indicated, offers 
the most reliable means of coping with the condition. For this reason 
the obstetrician should always carry in his bag the materials necessary 
for it, as they cannot usually be obtained promptly in an emergency. 

Too great stress cannot be laid upon the importance of observing the 
most rigorous aseptic technic in every intra-uterine manipulation under¬ 
taken for the purpose of checking postpartum hemorrhage. The natural 
tendency of the physician is to forget all other risks in his attempts to 
check the bleeding promptly. Such neglect, however, is frequently at¬ 
tended by most serious consequences, the patient being saved from death 
from hemorrhage merely to perish of infection a few days later. For 
this reason, therefore, the obstetrician will usually best subserve the 
interests of his patient by taking the time necessary for carefully disin- 





944 


HEMORRHAGE 


fecting his hands, or at least for drawing on a fresh pair of sterile 
gloves, before beginning any manipulations. In view of the possibility 
of such emergencies, more than one pair of gloves should always be 
boiled and be ready for instant use even in what promises to be the 
simplest case. 

After the actual hemorrhage has been checked, attention must be 
directed to the general condition of the patient.- When the shock is not 
profound and the pulse not particularly rapid, elevation of the foot of 
the bed and the application of hot bottles or bricks to the extremities 
will be all that is needed. In more severe cases, the administration of 
1/30 grain of strychnin hypodermically, 3 doses being given in prompt 
succession, if necessary, is useful, and may be supplemented by hypo¬ 
dermic injections of whisky or ether. Hot rectal enemata of equal 
parts of black coffee and salt solution are also valuable. 

When the patient is seriously shocked, sterile normal salt solution in 
large quantities—500 cubic centimeters being injected under each breast, 
and repeated as soon as absorption has occurred—will prove a useful 
temporary measure, and even more striking results may be obtained by 
administering it intravenously. In all such cases, however, preparations 
for actual transfusion should be made, and 500 to 750 of the donor’s 
blood injected, unless such improvement has resulted that its administra¬ 
tion appears needless. I am confident that by this means I have saved 
several lives, which otherwise would have been lost. 


INVERSION OF THE UTERUS 

This condition is a very rare, but important, cause of postpartum 
hemorrhage. According to Beckmann, not a single case occurred in 
250,000 labors in the St. Petersburg .Lying-in Hospital, while Madden 
noted it only once in 190,833 deliveries in Dublin. Many obstetricians 
in large practice have never seen a case, or have met with only a few 
examples of the condition. On the other hand, it is much more fre¬ 
quently noted in the practice of ignorant midwives. The historical and 
statistical aspects of the subject are fully dealt with in the articles of 
Beckmann, Browne, Holmes, and Vogel. 

Now and again the fundus of the uterus becomes inverted and comes 
into close contact with dr may protrude through the external os; while 
in rare instances the entire organ appears outside of the vulva, the condi¬ 
tion being respectively designated as incomplete and complete inversion, 
and prolapse of the inverted uterus (Pig. 678). In not a few cases the 
placenta remains attached to the inverted organ. 

Etiology. —For the production of the accident three factors are neces¬ 
sary: marked laxity or thinness of the uterine walls, particularly at the 
placental site, pressure from above or traction on the cord or placenta, 
and a patulous cervical canal. Its occurrence is also favored by a fundal 
insertion of the placenta. Inversion may occur spontaneously as the 
result of the intra-abdominal pressure or from the mere weight of the 
intestines, but in most cases it is attributable to violence resulting from 








XITERATURE 947 

Burger u. Graf. Zur Statistik der Placenta praevia. Monatsschr. f. Geb. u. Gyn., 
1907, xxv, 49-76. 

Colclough. The Treatment of Accidental Hemorrhage. J. Obst. and Gyn. Brit. 
Emp., 1902, ii, 153. * 

Coiiy elaire. Deux nouvelles observations d ’apoplexie utero-placentaire. Annales 
de gyn. et d’obst., 1912, ix, 416. 

Doranth. Statistisches iiber Placenta praevia. Chrobak’s Berichte aus der 2ten 
geb. gyn. Klinik in Wien, 1897, i, 77-119. 

Dorman. Premature Separation of the Normally Implanted Placenta, etc. 
Sloane Hospital Reports, 1913, i, 57. 

Dudley. The Modern Caesarean Section an Ideal Method of Treatment for Pla¬ 
centa Praevia. New York Med. Jour., 1900, lxxii, 754-760. 

Essen-Moller. L ’hemorrhagie retroplacentaire. Archives mens, d’obst. et de 
gyn., 1913, iv, 145. 

Quelques remarques sur le traitment du placenta praevia. Acta Gyn. Scandi- 
navica, 1921, i, 1-9. 

Fieux. La position de Trendelenburg dans les hemorrhagies graves de la deliv' 
erance. Bull, de la soc. d’obst. de Paris, 1913, ii, 787-792. 

Fraipont. Fissures peritoneales des corps uterine dans les cas de decollement, 
premature du placenta, etc. Annales de gyn. et d’obst., 1914, xi, 200. 

Fritsch. Zur Aetiologie der puerperalen Uterusinversion. Zentralbl. f. Gyn., 
1907, xxxi, 427-429. 

Gardiner. The Umbilical Cord. Surg. Gyn. & Obst., 1922, xxxiv, 252-256. 

Goodell. Concealed Accidental Haemorrhage of the Gravid Uterus. Amer. Jour. 
Obst., 1870, ii, 281-346. 

Gordon-Ley. Utero-placental (Accidental) Haemorrhage. Jour. Obst. & Gyn. Br. 
Emp., 1921, xxviii, 69-108. 

Harris. A Method of Performing Rapid Manual Dilatation of the Os Uteri, and 
Its Advantage in the Treatment of Placenta Praevia. Amer. Jour. Obst., 
1894, xxix, 37-49. 

Herff. Zur Lehre von der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1896, 
xxxv, 325-372. 

Hofmeier. Ueber Placenta praevia. Verh. d. deutschen Gesell. f. Gyn., 1888, 
159-163. 

I Zur Entstehung der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1894, xxxix, 1-17. 
Ueber Placenta praevia. Yerh. d. deutschen Gesell. f. Gyn., 1897, 204-225. 
Storungen der Schwangerschaft durch fehlerhaften Sitz der Placenta. WinckeUs 
Handbuch der Geb., 1904, ii, 1198-1259. 

Holmes. Inversio Uteri Complicating Placenta Praevia. Obstetrics, 1899, i, 297- 

311. 

Ablatio Placentae. Amer. Jour. Obst., 1901, xliv, 753-784. 

Hunter. Anatomical Description of the Human Gravid Uterus. Birmingham, 

1774. 

Jellett. The Place of Caesarean Section in the Treatment of Placenta Praevia. 
Lancet, 1910, i, 1271. 

Kaltenbacii. Zur Patliogenese der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 
1890, xviii, 1-7. 

Kermauner. Placenta praevia cervicalis. Beitrage z. Geb. u. Gyn., 1906, x, 241. 
Knauer. Einige seltenere Falle von Gebannutterzerreisung. Monatsschr. f. Geb. 
u. Gyn., 1903, xvii, 1279. 

Kronig. Zur Beliandlung der Placenta praevia. Zentralbl. f. Gyn., 1908. 
Kustner. Ueber Placenta praevia. Verh. d. deutschen Gesell. f. Gyn., 1897, 277- 
283. 


948 


HEMORRHAGE 


Kworotansky. Ueber Anatomie und Pathologie der Placenta, etc. Archiv f. 
Gyn., 1903, lxx, 113-192. 

Labhardt. Ueber Placenta cerviealis. Gyn. Rundschau, 1908, ii, 702-707. 

Beitrage zur Kenntniss der anatomischen grundlagen der post-partum Blut- 
ungen. Zeitschr. f. Geb. u. Gyn., 1910, lxvi, 374-408. 

Lomer. On Combined Turning in the Treatment of Placenta Praevia. Amer. 
Jour. Obst., 1884, xvii, 1233-1260. 

McNair. Concealed Accidental Hemorrhage with Intraperitoneal Bleeding. Proc. 

Roy. Soc. Med., 1917, x, 13-16. 

Madden. Quoted by Browne. 

Martin. Zur Aetiologie lethaler Atonien post partum. Monatsschr. f. Geb. u. 
Gyn., 1906, xxiii, 207-217. 

Momberg. Blutleere der uteren Korperhalfte. Zentralbl. f. Gyn., 1909, 716. 
Morse. Premature Separation of the Normally Implanted Placenta. Surg. Gyn. 

& Obst., 1918, xxvi, 133-138. 

Muller, W. Placenta praevia. Stuttgart, 1877. 

Munchmeyer. Ueber den Yorfall der Nachgeburt bei regelmassigem Sitze 
derselben. Archiv f. Gyn., 1888, xxxiii, 486-497. 

Olshausen. Paralyse der Placentar-insertionsstelle. Schroeder’s Lehrbuch der 
Geb., XIII. Aufl., 1899, 775. 

Pinard. De la rupture prematuree, dite spontanee, des membranes, etc. Annales 
d’obst. et de gyn., 1886, xxv, 171-179; 321-345. 

Pinard et Varnier. Decollement premature par brievete du cordon de placenta 
normalement insere. Etudes d’anat. obst., 1892, 57. 

Ponfick. Zur Anatomie der Placenta praevia. Archiv f. Gyn., 1900, lx, 147-173. 
Portal. La pratique des accouchements, etc. Paris, 1685. 

Portes. Pathogenie et traitement de Uapoplexie utero-placentaire. Gyn. et 

Obst., 1923, vii, 56-74. 

Rigby. An Essay on the Uterine Haemorrhage which Precedes the Delivery of the 
Full-grown Foetus. London, 1776. 

Schacher. De placentae uterinae morbis. Lipsiae, 1709. 

Schickele. Die vorzeitige Losung der normal sitzenden Placenta. Beitrage zur 
Geb. u. Gyn., 1904, viii, 357-364. 

Seitz. Zwei sub partu verstorbene Falle von Eklampsie, etc. Archiv. f. Gyn., 1903, 
lxix, 71-99. 

Sellheim. Die Gefahren der natiirlichen Geburtsbestrebungen bei Placenta 
praevia, etc. Zentralbl. f. Gyn., 1908, 1297-1311. 

Smellie. A Treatise on the Theory and Practice of Midwifery, 1752. 

Spiegelberg. Die Inversion der Gebarmutter. Lehrbuch der Geb., 1891, III. 
Aufl., 599-607. 

Stoeckel. Zur Therapie du Placenta praevia. Monatsschr. f. Geb. u. Gyn., 1923, 
lxi, 52-62. 

Strassmann. Ueber Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 529- 
546. 

Placenta praevia. Archiv f. Gyn., 1902, xxvii, 112-275. 

Stratz. Behandlung der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1915, lxxvi, 
713-728. 

Iait. Ou the Treatment of Unavoidable Haemorrhage by Removal of the Uterus. 
Med. Record, 1899, lv, No. 9. 

Tarnier et Budin. Hemorrhagie par insertion vicieuse du placenta. Traite de 
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Thompson, the 'treatment of Placenta Previa, together with the Anatomical 
Description of Two Specimens. Bull. Johns Hopkins Hosp., 1921, xxxii, 
228-233. 






LITERATURE 


949 


Titus and Andrews. Frozen Sections through the Uterus of a "Woman Dying 
from Central Placenta Previa. Am. Jour. Obst. & Gyn., 1923 (not yet pub¬ 
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Veit. Ueber die Behandlung der Blutungen unmittelbar nach der Geburt. 

Zeitschr. f. Geb. u. Gyn., 1895, xxxi, 214-225. 

Vogel. Beitrag zur Lehre von der Inversio uteri. Zeitschr. f. Geb. u. Gyn., 1900, 
xlii, 490-525. 

Weiss. Ueber vorzeitige Losung der normal sitzenden Placenta. Archiv f. Gyn., 
1897, xlvi, 256-291. 

Zur Kasuistik der Placenta prsevia centralis. Zentralbl. f. Gyn., 1897, xxi, 
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Premature Separation of the Normally Implanted Placenta. Surg. Gyn. & Obst., 
1915, xxi, 541-554. 

The Tolerance of Freshly Delivered Women to Excessive Loss of Blood. Am. 
Jour. Obst., 1919, lxxx, 1-17. 

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f. Geb. u. Gyn., 1885, xi, 398-408. 

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Am. Jour. Obst., 1906, liv, No. 5. 

Zuntz. Gesammtblutmenge in der Graviditat. Zentralbl. f. Gyn., 1911, 1365- 
1369. 






CHAPTER XLI 


INJURIES TO THE BIRTH CANAL 

INJURIES TO THE VULVAL OUTLET 

In the chapter upon the Conduct of Normal Labor reference was 
made to the frequency of perineal lacerations, and emphasis was laid 
upon the necessity for repairing them immediately after the birth of the 
child. 

More rarely tears occur about the anterior portion of the vulva. In 
spontaneous labor these seldom amount to more than slight abrasions 
upon the inner surfaces of the labia minora, hut in forceps deliveries, 
especially when the handles have been unduly elevated, serious lesions 
may follow the compression of the tissues between the pubic arch and 
the blades of the instrument. Now and again the labia minora are 
completely severed or torn loose from their connections, or deep tears 
occur on either side of the urethra implicating the vessels supplying the 
clitoris and giving rise to profuse hemorrhage; while following pubi- 
otomy, such tears may communicate with the pubic wound. 


INJURIES TO THE VAGINA 

With the exception of the most superficial varieties, which are limited 
to the mucous membrane of the fourchette, all perineal lacerations are 
accompanied by more or less injury to the lower portion of the vagina. 
Such tears rarely occur in the median line, but extend a variable dis¬ 
tance up one or both vaginal sulci, being sufficiently deep to involve 
some fibers of the levator ani muscle. Bilateral lacerations of this 
variety are usually unequal in length and are separated from one another 
by a tongue-shaped portion of mucosa which represents the lower end 
of the posterior column of the vagina (Fig. 321). 

These injuries should always be looked for, and their repair should 
form a part of every operation for the restoration of a lacerated perineum. 
If this precaution is neglected and the external wound alone is sutured, 
the patient will eventually present symptoms due to relaxation of the 
vaginal outlet, even though the perineum proper may be in perfect 
condition. 

Isolated tears involving the middle or upper third of the vagina, and 
unassociated with lacerations of the perineum or cervix, are very rarely 
observed. They are usually longitudinal, and result from injuries sus¬ 
tained during a forceps operation, though now and again they follow 
spontaneous delivery. They frequently extend deeply into the underlying 

950 


INJURIES TO THE VAGINA 


951 


tissues, and may give rise to a copious hemorrhage, which, however, is 
readily controlled by a few sutures. Their presence is readily overlooked, 
inasmuch as they can be recognized only after the vaginal walls have 
been spread apart by means of a speculum. 

More important are the injuries to the levator ani muscles, which 
are not associated with tears through the vaginal mucosa, and conse¬ 
quently usually escape immediate detection. As a result of overdis- 
tention of the birth canal, there may occur a submucous separation of 
certain fibers of the muscle, or at least so great a diminution in its 
tonicity, that it can no longer properly fulfill its function as the pelvic 
diaphragm. In such cases the patient sooner or later suffers just as 
severely from symptoms of relaxation as if a deeply lacerated perineum 
had been left unrepaired. Although the accident can sometimes be 
avoided by an intelligent use of forceps when the second stage of labor 
is unduly prolonged, it frequently follows spontaneous and rapid delivery. 

Lesions of the upper third of the vagina are extremely uncommon, 
unless they represent the extension of deep cervical tears into the fornix. 
In very rare instances, however, the cervix may be entirely or partially 
torn loose from its vaginal attachment, rupture in other cases occurring 
in either the anterior, posterior, or lateral fornix. ITugenberger, in 1875, 
collected 40 cases of this accident from the literature, and designated it 
as colpaporrhexis ; while Kaufmann, in 1901, estimated that something 
more than 100 cases have been recorded altogether. 

The accident is somewhat analogous to rupture of the lower uterine 
segment, and follows energetic efforts on the part of the uterus to over¬ 
come some obstacle to the passage of the child. As a result of the 
retraction of Bandl’s ring, so great a strain may be exerted upon the 
cervix that it is torn loose from its vaginal attachment. It is commonly 
taught that colpaporrhexis is possibly only in those cases in which the 
lips of the cervix are not compressed between the presenting part and 
the pelvic wall, but are free to follow the retracting uterus. While 
colpaporrhexis sometimes occurs spontaneously, it more frequently fol¬ 
lows brutal and unskillful use of forceps. 

The symptoms are identical with those following rupture of the 
uterus, and will be considered under that heading. Immediately fol¬ 
lowing the rupture, the child may escape into the peritoneal cavity, 
after which the intestines may protrude into the vaginal canal, as in 
a case reported by Ross. 

The diagnosis is made solely by the sense of touch, as the clinical 
symptoms do not differ from those following rupture of the uterus. 
The prognosis is extremely unfavorable, 60 to 75 per cent, ol the cases 

reported in the literature having ended fatally. 

Most authorities recommend treating the condition by means of 
a vaginal pack, a procedure which probably explains in part the high 
mortality I however, agree with Schick that laparotomy offers the best 
chance for successfully coping with this emergency, since m this way 
one can obtain an accurate idea of the extent of the injury, when the 
torn surfaces may be united by sutures, or, failing that, the uterus may 

be removed. 






952 


INJURIES TO THE BIRTH CANAL 


LESIONS OF THE CERVIX 

Slight degrees of cervical laceration must be regarded as an inevitable 
accompaniment of childbirth. Such tears, however, heal rapidly and 
rarely give rise to symptoms. In healing they cause a material change in 
the shape of the external os, and thereby afford us a means of determin¬ 
ing whether a woman has borne children or not. 

In other cases the tears are deeper, implicating one or both sides of 
the cervix and may extend up to or beyond the vaginal junction. In 



Fig. 678. —Annular Detachment of Cervix. Specimen Cast off before the Birth 
of Child, Showing Undulated and Rigid External Os and Obliterated Cer¬ 
vical Canal Seen from within. XI. 

rarer instances the laceration may extend across the vaginal fornix or 
into the lower uterine segment, and occasionally open up the base of 
the broad ligament. Such extensive lesions frequently involve vessels 
of considerable size, and are then associated with profuse hemorrhage. 

Deep cervical tears occasionally occur during the course of sponta¬ 
neous labor, and under such circumstances their genesis is not always 
readily explainable. More usually, however, they follow rapid manual 
or instrumental dilatation, especially in eclampsia, placenta previa, or in 
the ^rious types of cervical dystocia. Moreover, they are apt to result 
fi om attempts at delivery through an imperfectly dilated cervix, no 
matter whether forceps or version be employed. 












LESIONS OF THE CERVIX 


953 


Occasionally, even in spontaneous labors, the edematous anterior lip 
of the cervix may be caught between the head and the symphysis pubis 
and be compressed until it undergoes necrotic changes and separation 
occurs. In still rarer instances the entire vaginal portion may be torn 
loose from the rest of the cervix. According to Boudreau, this so-called 
annular or circular detachment of the cervix usually occurs in elderly 
primiparae when the pains are strong and a serious obstacle to delivery 
is offered by an imperfectly dilated os externum. 

Symptoms.— In all lesions involving the cervix there is usually no 
escape of blood until after the birth of the child, when the hemorrhage 
may be profuse. In many cases, however, the bleeding is so slight that 
the condition would pass unrecognized were it not detected upon vaginal 
examination. When one lip of the vaginal portion of the cervix is torn 
off, there is usually very little hemorrhage, for the reason that the tissues 
have been so compressed before the occurrence of the accident that the 
vessels have undergone thrombosis; likewise, circular detachment of 
the cervix is often not followed by bleeding. 

Slight cervical tears heal spontaneously, and extensive lacerations 
have a similar tendency, but perfect union rarely results. They afford 
to any pathogenic microorganisms which may be present a ready portal 
of entry into the lymphatics at the base of the broad ligament. 

Diagnosis.— A deep cervical tear should always be suspected in cases 
of profuse hemorrhage coming on during the third stage of labor, if 
the hand applied over the lower abdomen can feel that the uterus is 
firmly contracted. For a positive diagnosis, however, a thorough exami¬ 
nation is necessary. Owing to the flabby condition of the cervix imme¬ 
diately after delivery mere digital examination is often unsatisfactory, 
and the extent of the injury can be fully appreciated only after drawing 
the cervix down to the vulva and carefully subjecting it to direct in¬ 
spection. 

In view of the frequency with which deep tears follow artificial 
dilatation, and difficult breech extractions and forceps operations, the 
cervix in all such cases should be inspected at the conclusion ot flic 
third stage, even if there be no bleeding; and if a tear is discovered, 
it should be united by sutures as a prophylactic measure. Annular 
detachment of the vaginal portion of the cervix should be diagnosticated 
whenever an irregular mass of tissue having a circular opening in its 
center is cast off before or after the birth of the child. 

Treatment. —Deep cervical tears accompanied by hemorrhage should 
be immediately repaired, the introduction of a few sutures readily check¬ 
ing the flow of blood. On the other hand, if there be no hemonhage, 
the condition usually escapes detection unless specifically looked foi. I 
have already indicated the advisability of inspecting the cervix after 
certain operative procedures; but I consider its routine employment 
unnecessary after normal labor, as I hold that the benefits following 
the repair of all tears will be more than counterbalanced by the increased 
incidence of infection resulting from the necessary manipulations. More¬ 
over, the majority of such tears heal spontaneously, and in the exceptional 


954 


INJURIES TO THE BIRTH CANAL 



cases in which this does not occur better results are obtained by a 
secondary operation performed in the latter part of the puerperium. 

The treatment of cervical tears associated with hemorrhage varies 
with the extent of the lesion. When the laceration is limited to the 
cervix, or even when it extends w r ell into the vaginal fornix, satisfactory 
results are obtained by the introduction of sutures after bringing the 
cervix into view at the vulva. This is effected by having an assistant 
make firm downward pressure upon the uterus, while at the same time 




Fig. 679. —Lacerated Cervix Drawn down to Vulva, Preparatory to Repair 

(Bumm). 

the operator exerts strong traction by means of a bullet forceps inserted 
into either lip of the cervix, the vaginal walls being held apart by means 
of suitable retractors (Eig. 679). As the hemorrhage usually comes from 
the upper angle of the wound, it is advisable to apply the first suture 
in that situation, since if the suturing is begun at the free end of the 
tear a dead space is often left toward its upper extremity, from which 
subsequent hemorrhage may occur. Chromicized catgut sutures should 
be employed, as they do not have to be removed. The beginner is 
cautioned against too great a regard for appearances and attempting to 
give the cervix too normal a look, inasmuch as the retraction occurring 
within the next few days may lead to such constriction of its lumen 
as to cause retention of the lochial discharge. 







RUPTURE OF THE UTERUS 


955 


Many authorities recommend a tight vaginal pack in this class of 
cases. No doubt it will usually check the hemorrhage and may be em¬ 
ployed in an emergency, but it does not compare in efficiency with repair 
by suture. In the rare cases in which the wound extends through the 
broad ligament into the peritoneal cavity a tight pack may be introduced, 
provided there is no serious hemorrhage; but in all other cases the only 
satisfactory method of dealing with the condition is by laparotomy. 

The treatment of tears of the upper part of the cervix which involve 
the lower uterine segment will be considered in the following section. 

RUPTURE OF THE UTERUS 

This accident, which is one of the most serious with which the 
obstetrician can be confronted, seldom occurs except in prolonged and 
obstructive labors, although instances of spontaneous rupture during 
pregnancy are not unknown. 

While spontaneous rupture occurs more frequently in the last months, 
it may be met with at any period of pregnancy. Thus 31 out of 78 
cases collected by Baisch were observed during the first five months of 
pregnancy. In the first half of gestation the accident is usually due 
to pregnancy in the interstitial portion of the tube or in a bicornuate 
or infantile uterus, or to excessive invasion of the uterine wall by foetal 
elements. In the latter months the condition is usually associated with 
the presence of scar tissue in the uterine wall, which yields gradually 
with the increasing distention of the organ. Accordingly it occurs in 
1 or 2 per cent, of women who had previously been subjected to cesarean 
section, or in women whose uteri had been previously perforated or 
otherwise injured during curettage or some other operative procedure. 
Very exceptionally the accident may be attributed to lack of hypertrophy 
of the uterine wall at the fundal region; while Poroschin considers that 
it may be due to the scanty development or relative absence of elastic 
tissue. Alexandroff, Jellinghaus, and others are inclined to attribute 
certain cases to inherent weakness of the uterine walls resulting from 
the excessive formation of connective tissue following the removal of an 
adherent placenta in previous pregnancies. Schafer has reported a case 
due to diffuse adenomyometritis, and has collected the literature up 
to 1918. 

In spontaneous rupture occurring during pregnancy, the lesion is 
almost invariably situated in the upper portion of the uterus. This is in 
marked contrast to the conditions observed at the time of labor, when 
the rupture is usually limited to the lower segment, and clearly indicates 
that radically different etiological factors must be concerned. Contrary 
to the statement of Blind that the rupture nearly always occurs in the 
neighborhood of the fundus, Baisch found that it was situated upon the 
anterior or posterior wall in 32 out of 56 cases in which the location 
of the rupture has been accurately described. 

The symptoms, diagnosis, prognosis, and treatment of this condition 
are identical with those following rupture of the uterus occurring at the 





956 


INJURIES TO THE BIRTH CANAL 


time of labor. It should be noted, however, that in a number of the cases 
reported in the literature the hemorrhage following the accident was so 
slight as not to give rise to symptoms, the condition escaping recognition 
until operative procedures became necessary for the removal of the foetus 
lying free in the abdominal cavity. 

In very exceptional instances, as in the cases reported by Leopold 
and Henrotin, the placenta remained in the uterus, while the foetus, 
surrounded by its membranes, escaped into the peritoneal cavity, where 
it went on to further development— utero-dbdominal pregnancy. Such 
an occurrence is very unusual, as escape into the peritoneal cavity is 
ordinarily synonymous with foetal death. 

Etiology.—Rupture of the uterus at the time of labor occurs once in 
every 500 or 1,000 deliveries, and is a most serious complication, as it 
nearly always leads to the death of the foetus, and frequently to that of 
the mother as well. 

We are indebted to Bandl for the first clear explanation as to its 
mode of production, its etiology being inseparably connected with the 
doctrine of the lower uterine segment and the formation of the con¬ 
traction ring. 

Normally, under the influence of labor pains the uterus becomes 
differentiated into two portions, separated by a circular ridge of tissue, 
to which the term contraction ring is usually applied. The upper, by 
its contractions, serves to expel the child, while the lower undergoes 
dilatation and passively forms part of the canal through which the 
contents of the uterus are expelled. On the other hand, when a serious 
obstacle is opposed to the passage of the child, the active portion of the 
uterus is stimulated to more forcible efforts. As it contracts it likewise 
slowly becomes retracted, its lower margin—the contraction ring— 
eventually occupying a much higher level than usual. As a result, 
particularly if the lips of the cervix are caught between the presenting 
part and the superior strait, powerful upward traction is exerted upon 
the passive lower segment of the uterus, which becomes more and more 
stretched, and thinner and thinner. At the same time the contraction 
ring separating the two portions becomes thicker and more prominent, 
so that it can readily be palpated, and occasionally seen as a transverse 
or oblique ridge extending across the abdomen just below or perhaps 
on a level with the umbilicus. The round ligaments, likewise, are sub¬ 
jected to an abnormal strain and remain tense even in the intervals 
between the uterine contractions. 

As the process goes on the lower segment becomes extremely sensitive 
to pressure, and the contractions increase progressively in frequency 
and intensity, until eventually the upper segment of the uterus passes 
into a tetanic condition, and no longer alternates between contraction 
and relaxation. At the same time the contraction ring becomes more 
prominent on palpation. The pulse becomes more rapid, and as a result 
of the increased suffering the patient presents a worn and haggard 
appearance. Such a condition indicates that rupture is imminent and 
■will occur unless delivery is promptly effected in a conservative manner. 

Generally speaking, rupture is more apt to take place when one 




RUPTURE OF THE UTERUS 


957 


side of the lower uterine segment is subjected to greater stretching than 
the other. In transverse presentations this condition is most marked 
on the side of the uterus occupied by the head. A similar danger threat¬ 
ens the posterior wall when the child presents by the head and the 
patient has a markedly pendulous abdomen. 

Excessive stietching of the lower uterine segment, with consequent 
danger of rupture, is favored by any factor which interferes with the 
birth of the child, and more particularly with the entrance of the pre¬ 
senting pait into the pelvis. Such conditions are most frequently 
afforded by contracted pelves, neglected transverse presentations, hydro¬ 
cephalus, excessive size of the child, and, in fact, by any obstacle to 
labor. In recent years, the injudicious use of pituitary extract in cases 
of disproportion has resulted in the production of many uterine ruptures, 
which are frequently accompanied by unusually extensive injury. The 
following analysis by Merz shows the etiological factors concerned in 
the production of 160 cases of rupture of the uterus: 


•Contracted pelvis. 70 

Neglected transverse presentation . 26 

Hydrocephalus. 18 

Large child or unfavorable presentation. 10 

Stenosis of birth canal. 6 

Trauma. 5 

Pelvic tumor. 3 

Ascites. 1 

Operative procedures. 21 


It is generally held that excessive stretching of the lower uterine 
segment can occur only after a prolonged second stage, but Goldner, in 
1903, reported 19 instances in which rupture appeared imminent before 
the escape of the amniotic fluid. In these cases the condition was 
associated with oligohydramnios, very resistant membranes, or a rigid 
cervix. 

It is customary to distinguish between spontaneous and traumatic 
rupture of the uterus. In the former the accident occurs spontaneously, 
while in the latter it is the result of ill-judged manipulations on the 
part of the obstetrician in a uterus whose lower segment is so thinned 
out and distended that the slightest violence proves too much for its 
resisting powers. In other cases it may result from the upward exten¬ 
sion of cervical tears, following rapid manual or instrumental dilatation 
of the cervix. 

Traumatic rupture occurs relatively frequently when version is at¬ 
tempted in neglected transverse presentations. The proper treatment of 
this complication requires the utmost nicety of judgment, as it is oft- 
times extremely difficult to determine whether the lower uterine segment 
is so thinned out as to contra-indicate attempts at version, the operation 
being sometimes readily accomplished under anesthesia in cases in which, 
at first sight, it had appeared impracticable; whereas, in others, in 
which it seemed that the necessary manipulations would be without 
danger, rupture follows the mere introduction of the hand. Moreover, 
there is a marked difference in the rapidity with which overstretching 
of the lower uterine segment comes about, the condition supervening 
















958 


INJURIES TO THE BIRTH CANAL 


very rapidly in some cases, while in others many hours of strong, second- 
stage pains may be necessary for its production. 

Certain women seem to possess a predisposition toward rupture of 
the uterus, this assumption being supported by the fact that not a few 
cases of repeated rupture appear in the literature. Thus, Mikhine 
found records of 13 patients, 6 of whom died as a result of a second 
rupture, the latter occurring in tissues already weakened by the previous 
accident. 

Pathology.—Spontaneous rupture of the uterus occurring at the time 
of labor is limited almost entirely to the lower uterine segment, the 
rent usually pursuing an oblique direction; although when it is in the 



Fig. 680 . —Longitudinal Section through Woman Dying from Rupture of the 

Uterus (Zweifel). 


immediate vicinity of the cervix it frequently extends transversely. On 
the other hand, it is usually longitudinal when it occurs in the portion 
of the uterus adjacent to the broad ligament, and, according to Freund, 
when it occurs spontaneously in neglected transverse presentations. 

It is customary to distinguish between complete and incomplete rup¬ 
ture, according as the laceration communicates directly with the ab¬ 
dominal cavity or is separated from it by the peritoneal covering ot 
the uterus or broad ligament. The former is the more common, Merz 
having collected 118 complete as against 46 incomplete ruptures. 
Lobenstine noted 46 and 29 cases respectively in the New York Lying-in 
Hospital. 

Incomplete ruptures frequently extend into the broad ligament; in 
such circumstances the hemorrhage often occurs less rapidly than in 
the complete variety, the blood slowly accumulating between the leaflets 
and leading to the separation of the peritoneum from the surrounding 
viscera, with the consequent formation of a large subperitoneal hema¬ 
toma. Occasionally, an effusion of blood sufficiently copious to cause 
















RUPTURE OF THE UTERUS 


959 


the death of the patient may be inclosed between the structures. More 
frequently, however, the fatal issue does not occur until rupture of the 
hematoma into the peritoneal cavity relieves the pressure which had 
previously, to some extent, restrained the bleeding. 

Although occurring primarily in the lower uterine segment, it is 
not unusual for the laceration to extend further upward into the body 
of the uterus or downward through the cervix into the vagina. The 
tear itself usually presents jagged, irregular markings which are stained 
with blood. 

Following complete rupture, the uterine contents may escape into 
the peritoneal cavity, while in the incomplete variety they may remain 
within the uterus, or come to lie beneath the serous covering of the 
uterus or between the leaflets of the broad ligament. When the pre¬ 
senting part is firmly engaged at the time of rupture, only a portion 
of the foetus may escape, the rest remaining in the uterine cavity. 

Symptoms.—The symptoms of actual rupture vary considerably. 
During the latter months of pregnancy, whether it occurs spontaneously 
or as the result of traumatism, the patient usually experiences sharp 
abdominal pain. In some cases marked symptoms of collapse immedi¬ 
ately supervene, but in many instances the patient merely complains of 
malaise, grave symptoms only occurring later as the result of infection 
or of putrefaction of the foetus. Thus, in one of my cases, two weeks 
elapsed before the appearance of alarming symptoms; while in another, 
in which the scar of a previous cesarean section had given way and 
the entire product of conception had been expelled into the peritoneal 
cavity, the patient walked to the dispensary the day after the accident, 
and presented a pulse of only 80 when placed upon the operating table. 
In‘the earlier months, on the other hand, profuse hemorrhage is the rule, 
and the patient rapidly succumbs to acute anemia if not operated upon. 

If the accident occurs at the time of labor, the patient, after pre¬ 
senting for some time the premonitory signs of the accident, suddenly, 
at the height of an intense uterine contraction or during an intra-uterine 
manipulation, complains of a sharp, shooting pain in the lower abdomen, 
and frequently cries out that something has given way inside of her. 
At the same time the lower uterine segment becomes much more sensitive 
to pressure. Immediately following these symptoms there is an absolute 
cessation of the uterine contractions, and the patient, who had previously 
been in intense agony, suddenly experiences great relief. At the same 
time there is usually some external hemorrhage, although in many cases 
it is very slight in amount. 

Palpation or vaginal examination shows that the presenting part has 
slipped away from the superior strait and has become movable, while a 
hard, round body, which represents the firmly contracted uterus, can be 
felt alongside of the foetus. Naturally, if the uterine contents have 
escaped into the abdominal cavity, the presenting part cannot be felt 
on vaginal examination. 

As a rule, shortly after the occurrence of complete rupture, the 
patient presents symptoms of collapse, the pulse increases gieatly in 
rapidity, loses tone, and takes on a filiform character, the face becomes 





960 


INJURIES TO THE BIRTH CANAL 


pallid, assumes a drawn appearance, and is often covered with beads 
of sweat. If the hemorrhage has been copious, she may complain of 
chilliness, disturbances of vision, and air hunger, and eventually pass 
into an unconscious state. Symptoms of collapse, however, do not always 
appear immediately, but are sometimes deferred for several houis after 
rupture, being less marked when the child remains partially within the 
uterus. After incomplete rupture, on the other hand, the immediate 
symptoms are sometimes very slight, but increase in severity as the 
subperitoneal hematoma becomes larger, while actual symptoms of col¬ 
lapse sometimes do not appear until secondary rupture into the peii- 
toneal cavity has taken place. 

Occasionally after incomplete rupture, emphysematous crackling can 
be elicited in the tissues of the anterior abdominal wall, 14 cases of this 
character having been collected by Dischler. It is probably due to the 
invasion of the subperitoneal connective tissue by Bacillus aerogenes 
capsulatus. It is true that bacteriological proof has not been adduced 
in support of this statement, but the fact that the women had been in 
labor for many hours, and that many of the children were more or less 
putrefied, speaks strongly in favor of such a view. 

Diagnosis.—In cases of spontaneous rupture during pregnancy the 
diagnosis is not always easy. If the collapse is profound, it should at 
once lead to a provisional diagnosis of intra-abdominal hemorrhage, but 
in other cases the condition may escape detection until the appearance 
of peritonitic symptoms. Generally speaking, it may be said that a 
rapid pulse, slight elevation of temperature, and abdominal distention 
associated with very distinct palpation of the foetus, should always be 
regarded with grave suspicion, particularly when preceded by a history 
of traumatism. 

On the other hand, the diagnosis is usually easy when the accident 
occurs at the time of labor, especially if the patient has been under 
supervision during its course. If she is not seen until later the charac¬ 
teristic history and the collapse are almost pathognomonic, the only other 
conditions in which the latter is noted before delivery being in cases 
of rupture of an advanced extra-uterine pregnancy, or of the premature 
separation of the normally implanted placenta. 

If the child has escaped into the abdominal cavity it is much more 
readily felt on palpation than usual, while on one side of it the hard, 
rounded body of the uterus can be detected. Moreover, vaginal exami¬ 
nation sometimes reveals the existence of a tear in the uterine wall 
through which the fingers can be passed into the abdominal cavity, 
where they come in contact with the intestines, although failure to 
detect the tear by no means indicates its absence. Again, the fact that 
the presenting part can no longer be felt is conclusive evidence that the 
foetus has escaped from the uterus. 

Prognosis.—The chances for the child are almost uniformly bad, since 
it frequently succumbs before the occurrence of the accident. On the 
other hand, if it has survived up to that time, its only chance of living 
is afforded by immediate extraction, asphyxia, the result of the separa¬ 
tion of the placenta, being otherwise inevitable. If left to themselves, 




RUPTURE OF THE UTERUS 


961 


the vast majority of the mothers die from hemorrhage or infection, 
although spontaneous recovery has been noted in exceptional cases. In 
the 23 cases reported by Scipiades, which came to autopsy, death was 
due to infection in 52 per cent., to hemorrhage in 39 per cent., and to 
hemorrhage and shock in 44 per cent. 

Death from hemorrhage usually occurs within the first few hours, 
though ocasionally it may be deferred for forty-eight hours; in infection 
the fatal termination may not occur for some days. 

Spontaneous recovery is least likely when the child has escaped into 
the abdominal cavity, though isolated instances are on record in which 
the patient has survived even such an accident. In such circumstances 
the child is usually surrounded by foetal membranes, and after its death 
may undergo any one of the several eventualities mentioned in the 
chapter on Extra-uterine Pregnancy. So far as the women are con¬ 
cerned, even if properly treated, the mortality is very high, at least 
one-third succumbing. 

Treatment.— («) Prophylactic .—Intelligent care of the lying-in 
woman should almost entirely do away with this accident. Accordingly, 
it occurs very rarely in well-regulated hospitals and comparatively fre¬ 
quently in the homes of the poor—in Scipiades’ series of 91 cases the 
respective incidence was 0.046 and 0.53 per cent. Whenever there is 
a possibility of the existence of an obstacle to the birth of the child, 
the obstetrician should always be on the alert for symptoms indicative 
of impending rupture. Transverse presentations should be promptly 
delivered by version as soon as the cervix is fully dilated; in head 
presentations failure of engagement after one hour of .strong second-stage 
pains should be regarded with suspicion, and, if the contraction ring 
rises up, labor should be promptly terminated by the most conservative 
procedure. In neglected cases decapitation in transverse and craniotomy 
in head presentations often promise the best results. Such procedures 
are the more justifiable in the circumstances, as the children are usually 
either already dead or have been exposed to such danger that their 
chances of being delivered alive are very slight. 

(h) Curative .—If the child is alive and still within the ruptured 
uterus, or if it has already escaped into the abdominal cavity, no attempt 
should be made to extract it per vaginam, but laparotomy should be 
immediately performed, and followed, after removal of the child, by 
whatever operative procedures may be deemed necessary—suture of the 
tear, supravaginal amputation, or total removal of the uterus. 

On the other hand, if the child is dead and still within the uterus, 
certain authorities recommend its delivery through the natural passages 
by the most feasible and conservative procedure, after which, as well 
as in those cases which are not seen until after delivery per vaginam 
or in which the uterine rupture was not recognized until later, various 
procedures have been suggested by different authorities. I do not 
advocate delivering the child through the natural passages in any case, 
but I would especially warn against any attempt to do so after it 
had escaped into the peritoneal cavity, as the necessary manipulations 
will inevitably add to the shock from which the patient is suffering, and 










962 


INJURIES TO THE BIRTH CANAL 


lead to an increase in the size of the tear and render its repair more 
difficult when the abdomen is opened. 

I believe that in hospital practice the best results will follow lapa¬ 
rotomy, no matter what the character of the tear or the extent of the 
hemorrhage; for the reason that it is often difficult to determine the 
extent of the laceration, and furthermore that it is impossible to foretell 
whether the hemorrhage can be controlled by simple procedures. I 
therefore agree with Fritsch, Varnier, Zweifel, and Munro Kerr, who hold 
that it is onty by opening the abdomen that one can be assured against 
all further risk of hemorrhage. In general, the best results are obtained 
by amputating the uterus. At first glance it would appear very simple 
to repair the rent by sutures, and thus preserve the organ. But in 
practice it is not so simple, for in many instances the wound conditions 
are so complicated and the edges of the rent so damaged by hemorrhage 
and trauma, that accurate coaptation by means of sutures is out of the 
question. Furthermore, the fact that the patient has probably already 
been infected would contra-indicate any attempt to conserve the damaged 
tissues. On the other hand, if the patient cannot be removed to a 
hospital, and expert surgical aid is not available, one must be content 
with the employment of palliative measures after having delivered the 
child and placenta through the natural passages. In such circumstances, 
the results are usually disastrous following complete rupture, but are 
sometimes surprisingly good in the incomplete variety. 

Many authorities contend that, inasmuch as the danger to be ap¬ 
prehended in cases of incomplete rupture is hemorrhage, laparotomy 
should be performed only when the loss of blood is profuse, but that in 
all other cases equally good, if not better, results may be obtained by 
draining or packing the rupture from the vagina. Schmit, .Klien, Scipi- 
ades, and others have collected large series of cases which apparently 
bear out this contention. 

My own experience, however, leads me to believe it irrational to adopt 
such procedures as a matter of choice, as occasionally women who are 
apparently in excellent condition shortly after the occurrence of the 
rupture may begin to bleed profusely some hours later, and may die 
before operative measures can be instituted. Furthermore, I do not 
believe that the statistical evidence thus far adduced gives a correct idea 
of the relative merits of the two methods of treatment, for the reason 
that packing is usually employed in the milder and more favorable cases, 
whereas radical surgical measures have been practically limited to the 
desperate cases. 


INSTRUMENTAL PERFORATION OF THE UTERUS 

Reference has already been made to perforation of the uterus follow¬ 
ing attempts at criminal abortion or in the effort to remove placental 
tissue by means of curette or polypus forceps, after an incomplete 
abortion. Similar accidents likewise occasionally occur as the result of 
want of skill on the part of the obstetrician in full-term labor, when 











LITERATURE 


963 


either the uterus or the vaginal vault may be perforated. As has already 
been pointed out, in cases of this character, loops of intestine frequently 
prolapse through the rupture. In such circumstances laparotomy is the 
ideal treatment, though, in the absence of prolapse of the intestines 
cases are recorded in which recovery occurred spontaneously under what 
were apparently most unfavorable circumstances. 


PERFORATION OF THE GENITAL TRACT FOLLOWING NECROSIS 

In obstructed labor the tissues in various portions of the genital 
tract may be forcibly compressed between the head and the bony canal. 
If the pressure is transitory it is without significance; but if it is long 
continued necrosis results, and after a few days the area implicated 
sloughs away so that perforation follows. 

In most cases of this character the perforation occurs between the 
vagina and the bladder, giving rise to a vesicovaginal fistula. Less 
frequently the anterior lip of the cervix is compressed against the 
symphysis pubis, and an abnormal communication is eventually estab¬ 
lished between the cervical canal and the bladder —cervicovesical fistula. 

If the patient is not infected the fistulous tract frequently heals 
without further treatment. In other cases, however, it may persist, when 
a subsequent plastic operation becomes necessary for its cure. 

Occasionally the posterior wall of the uterus may be subjected to so 
much pressure against the promontory of the sacrum that necrosis re¬ 
sults, and a connection is established with Douglas’s culclesac. If infec¬ 
tion occurs the accident is usually followed by septic peritonitis. Fortu¬ 
nately, recovery usually follows without further complications, inasmuch 
as a localized peritonitis leads to the formation of adhesions between 
the posterior wall of the uterus and the pelvic peritoneum, thereby 
doing away with the possibility of a general peritoneal infection. It 
should be remembered that similar lesions may occur in the rare cases 
in which exostoses or bony spicules protrude from the walls of the birth 
canal, as in pelvis spinosa. 


LITERATURE 

Alexandroff. Ein Fall von Uterusruptur wahrend der Schwangerschaft. 

Monatssehr. f. Geb. u. Gyn., 1900, xii, 447-457. 

Baisch. Ueber Zerreissung der Gebarmutter in der Schwangerschaft. Beit rage. 

z. Geb. u. Gyn., 1903, vii, 248-283. 

Bandl. Ueber Ruptur des Uterus und ihre Mechanik. W len, 18/5. 

Blind. Beitrag zur Aetiologie der Uterusruptur wahrend der Schwangerschaft 
und unter der Geburt. D. I., Strassburg, 1892. 

Boudreau. L’arrachement circulate du col uterin pendant 1’accouchement. 

These de Toulouse, 1902. 

Dischler. Ueber subperitoneales Emphysem nach Ruptura uteri. Archiv f. Gyn., 
1898 lvi 199-217. 

Freund. Neuere Arbeiten iiber die Zerreissung der Gebarmutter. Zeitschr. f. 
Geb. u. Gyn., 1910, lxv, 735-759. 






964 


INJURIES TO THE BIRTH CANAL 


Fritsch. Ueber die Behandlung der Uterusruptur. Verb. d. deutschen Gesell. 
f. Gyn., 1895, 1-19. 

Goldner. Dehnung des unteren Uterinsegments bei stcliender Blase. Monatsschr 
f. Geb. u. Gyn., 1903, xviii, 491-512. 

Henrotin. Utero-abdoininal Gestation. The Practice of Obstetrics by American 
Authors, 1899, 386. 

Hugenberger. Ueber Ivolpaporrhexis in der Geburt. Petersburger med. Zeitschr. 
1875, v, Heft, 5. 

Jellinghaus. Ueber Uterusrupturen wahrend der Schwangerschaft. Archiv f 
Gyn., 1897, liv, 103-116. 

Kaufmann. Ueber die Zerreissung des Scheidengewolbes wahrend de.r Geburt 
Monatsschr. f. Geb. u. Gyn., 1901, xiii, 464-470. 

Kerr. Rupture of the Uterus and Its Treatment. Jour. Obst. and Gyn. Brit 
Empire, 1908, xiv, 1-22. 

Klien. Die operative und nicht operative Behandlung der Uterusruptur. Archiv 
f. Gyn., 1900, lxii, Heft 2. 

Leopold. Ausgetragene secundare Abdoininalschwange.rschaft nach Ruptura uter 
traumatica, etc. Archiv f. Gyn., 1896, lii, 376-388. 

Lobenstine. Rupture of the Uterus during Labor. Am. Jour. Obst., 1909, lx, 
810-852. 

Merz. Zur Behandlung der Uterusruptur. Archiv f. Gyn., 1894, xlv, 181-271. 
Mikhine. Un cas de recidive de rupture uterine. Annales de gyn. et d’obst., 

1902, lvii, 403-410. 

Peham. Ueber Uterusrupturen in Narben. Zentralbl. f. Gyn., 1902, xvi, 87-94. 
Poroschin. Zur Aetiologie der spontanen Uterusruptur wahrend Schwangerschaft 
und Geburt. Zentralbl. f. Gvn., 1398, xxii, 183. 

Ross. Lacerated and Punctured Wounds of the Genital Tract. Amer. Jour. Obst., 
1898, xxxvii, 449-469. 

Sanger. Ruptura uteri. Verh. der deutschen Gesell. f. Gyn., 1895, 19-86. 
Schafer. Zur Aetiologie der Scliwangerschaftsrupturen. Archiv. f. Gyn., 1918, 
cix, 284-301. 

Sciiick. Zerreissung des ScheidengewOlbes wahrend der Geburt. Prager med. 
Wochenschr., 1893, xxiii, 355, 367. 

Schmit. Ein Beitrag zur Therapie der Uterusruptur. Monatsschr. f. Geb. u. 
Gyn., 1900, xii, 325-342. 

Scipiades. Ueber die Zerreissung der Gebarmutter. Tauffer’s Abhandlungen aus 
dem Gebiete der Geb. u. Gyn., 1909, i, 168-304. 

Yarnier. Du traitement des .ruptures de 1 ’uterus. Annales de gyn. et d’obst., 
1901, lvi, 249-279. 

Zweifel. Ueber die Behandlung der Uterusruptur. Beitrage z. Geb. u. Gvn., 

1903, vii, 1-27. 












CHAPTER XLII 


PROLAPSE OF THE UMBILICAL CORD—ASPHYXIA NEONATORUM— 

SUDDEN DEATH DURING LABOR 

PROLAPSE OF THE UMBILICAL CORD 

It is customary to distinguish between presentation and prolapse of 
the funis or umbilical cord. In the former the cord can be palpated 
through the intact membranes, while in the latter a loop of it protrudes 
through the cervix into the vagina, and exceptionally emerges from the 

vulva. 

In general it may be said that any factor which interferes with 
the accurate adaptation of the presenting part to the superior strait 
predisposes to prolapse of the cord. Accordingly, the accident occurs 
most commonly in transverse and foot, and less often in frank breech 
presentations. On the other hand, it is rarely observed when the child 
presents by the head, unless accommodation is interfered with as a 
result of contracted pelvis, excessive development of the foetus, hydram- 
nios, or abnormal flaccidity of the lower uterine segment. For this 
reason it is much more common in multiparous than in primiparous 
women. 

Prolapse of the cord is without appreciable effect upon the course 
of labor so far as the mother is concerned. On the other hand, it is 
one of the frequent causes of foetal death, compression between the 
presenting part and the pelvic wall interfering with the circulation to 
such an extent that asphyxia and inevitable death often follow unless 
prompt delivery is effected. The danger is greater in vertex than in 
other presentations, for the reason that there is less likelihood that the 
cord will escape compression when the pelvic canal is filled out by the 
hard, rounded head than by the softer and more irregularly shaped part 
in other presentations. 

Presentation of the funis is diagnosticated when on palpation a soft, 
■pulsating, cordlike body can be felt through the membranes. In many 
instances, however, its recognition is only possible when the cord is in 

direct contact with the presenting part. 

Prolapse of the cord, on the other hand, is readily recognized, since 
on vaginal examination the fingers come directly in contact r\ ith a loop, 
while exceptionally it may be seen protruding from tire vul\a. In the 
former case mistakes are hardly possible if the foetus is alive, as distinct 
pulsations are felt, although in their absence the condition is sometimes 

1 overlooked on superficial examination. 

The possibility of prolapse of the cord should be particularly borne m 

965 









966 


SUDDEN DEATH DURING LABOR 


mind in normal multiparous women in whom the membranes rupture 
while the head is still freely movable above the superior strait. In 
such cases the sudden cessation of the foetal heart-beat renders the 
diagnosis almost certain, even without vaginal examination. 

Treatment. —The treatment to be pursued in any given case depends 
mainly upon the degree to which the cervix is dilated, and to a lesser 
extent upon the presentation of the child. In cases of presentation of 
the funis there is no immediate danger of compression so long as the 
membranes remain intact, and for this reason every precaution should 
be taken to avoid their premature rupture, vaginal examinations being 
made with the utmost gentleness. Furthermore, the obstetrician should 
hold himself in readiness to effect delivery as soon as the cervix is ! 
sufficiently dilated. 

If the cord prolapses under the observation of the obstetrician, the 
cervix is fully dilated, and no great disproportion exists, the life of 
the child can usually be saved. No attempt at reposition should be 
made, but delivery should be effected at once. In cephalic and trans¬ 
verse presentations version is usually the operation of choice, but forceps 
are indicated when the head is already deeply down in the pelvic canal. 
In breech presentations a foot should be brought down and extraction 
promptly completed. 

On the other hand, when the cervix is only partially dilated, the 
chances of a favorable outcome for the child are greatly diminished. 
If the cervical canal is obliterated and resistance is offered only bv the 
external os, manual dilatation followed by version and extraction may I 
give excellent results. On the other hand, if the condition of the cervix 
precludes manual dilatation, the chances for the child are poor, and the 
only hope lies in replacing the cord, and retaining it in place until the 
cervix dilates. For this purpose, if the presenting part is not deeply en¬ 
gaged, the patient should be placed in the knee-chest position, the entire ! 
hand introduced into the vagina, and an attempt made to push the cord 
up into the uterus and, if possible, to carry it over some projecting por¬ 
tion of the child’s body. If the cord remain in place the patient should 
be made to lie upon the side toward which the child’s back is directed 
in the hope of avoiding compression, and all danger is past if the head 
engages. 

In the majority of cases, however, the prolapse recurs again as soon 
as the hand is removed. In such circumstances an improvised repositor I 
will sometimes serve us in good stead, although the results attending 
its use are usually unsatisfactory. A piece of bobbin is firmly attached 
to the free end of a sterile bougie in such a manner as to leave a loop 
several inches long. This is then passed around the prolapsed cord 
and slipped over the tip of the bougie. By this means the cord can 
readily be carried up into the uterus, after which it may be freed from 
the repositor by bringing the loop in contact with a portion of the 
child and making traction upon it so as to cause it to slip off from the 
tip of the bougie. In the great majority of cases the condition recurs 
as soon as the repositor is removed; to insure against such an accident 
the bougie may be left in the uterus. 












ASPHYXIA 


967 


If, however/ all such maneuvers prove ineffectual, as is usually the 
case, the death of the child becomes almost inevitable, unless cesarean 
section is performed, which is feasible only when the patient is already 
in a hospital. On the other hand, if the pulsations in the cord are 
weak or have ceased altogether, no attempt at reposition should be made, 
inasmuch as the child has either already perished or will die before 
delivery can be effected. If, however, the cervix is fully dilated, such 
limitations do not hold good, as occasionally a child that is apparently 
hopelessly lost may be rescued by immediate delivery. 

* 

ASPHYXIA 

Normally the foetus while it remains in the uterus is in a condition 
of apnea, being satisfactorily supplied with oxygen by means of the 
placental circulation. As soon as delivery occurs, owing to the separa¬ 
tion of the placenta or to the great diminution in its area of attachment, 
this source of oxygen is entirely cut off, or so greatly reduced that 
the necessity for active respiration arises. Generally speaking, imperfect 
oxygenation should be considered as the primary factor in the establish¬ 
ment of this function, although numerous accessory causes come into 
play during the act of delivery and just after birth. 

Exceptionally, as the result of compression of the prolapsed cord, 
premature separation of the placenta, or much less commonly of tetanic 
contraction of the uterus, the normal supply of properly aerated blood 
through the umbilical vessels may be cut off or interfered with while 
the child is still within the uterus. Occasionally a similar condition may 
be brought about by compression against the symphysis of a cord which 
is wrapped around the neck of the child, while now and again asphyxia 
and even death may result when the head is on the perineum, owing 
to excessive retraction of the active segment of the uterus, with a conse-. 
quent diminution in the area of placental attachment. 

As a result of the action of any of these factors the child may take it 

first breath while still in the uterus or in the lower portion of the birth 

canal. In the former case it may draw a certain quantity of amniotic 

fluid into its lungs, and when respiration begins while the head is in 

the vagina, a certain amount of mucus is liable to be aspirated. In 

either event the needed oxygen is not obtained, and the resulting air 

hunger leads to increased respiratory efforts, which are nevertheless of 

no avail. Graduallv the accumulation of carbon dioxid and other ex- 

«/ 

crementitious materials in the foetal organism leads to such a pronounced 
decrease in the irritability of the medulla that eventually the attempts 
at respiration cease, the intervals between the pulsations of the heart 
become longer and longer, and the child dies from asphyxia. 

Again, pressure exerted upon the brain in difficult labors or in opera¬ 
tive procedures may lead to vagus irritation and consequent slowing of 
: the heart. As a result of the interference with the foetal circulation the 
blood becomes poorer in oxygen and richer in excrementitious material; 
this goes on until at last the irritability of the medulla becomes so 






968 


SUDDEN DEATH DURING LABOR 


lowered that the usual stimuli fail to call forth the first respiratory 
movement and asphyxia results. 

The most frequent causes of cerebral compression are attempts on 
the part of the uterus to force the head through a contncted superior 
strait, excessive pressure exerted by the blades of the forceps or during 
a breech extraction, and intracranial hemorrhage. When limited to the 
cerebral hemispheres a very considerable effusion of blood may occur 
without exerting an immediately deleterious effect upon the foetus; but 
if the base of the brain is implicated a much smaller amount may give 
rise to serious disturbances. 

Diagnosis.—The importance of watching for manifestations pointing 
to threatened intra-uterine asphyxia cannot be overestimated, inasmuch 
as their recognition frequently affords the indication for operative de¬ 
livery, without which the life of the child is inevitably lost. 

The most characteristic symptom is afforded by changes in the foetal 
pulse-rate. At first, as a result of momentary compression of the brain 
or interference with the placental circulation, it becomes slower with 
each uterine contraction, but regains its normal frequency in the intervals 
between the pains. As the condition becomes more serious, the remissions 
fail to occur and the pulse becomes slower and slower and eventually 
the heart ceases to beat. For practical purposes it is well to assume 
that a pulse-rate of 100 or less is incompatible with prolonged life for the 
foetus, and under such circumstances rapid delivery is indicated, provided 
it can be accomplished without too great risk for the mother. Excep¬ 
tionally, the first sign of asphyxia is a marked increase in the frequency 
of the foetal pulse, which may vary from 160 to 200. The acceleration, 
however, is only transient, and, as a rule, soon gives place to a marked 
slowing, which becomes still more perceptible as the fatal termination 
is approached. Such rules, however, have only an approximate value, 
and Baumm has pointed out their limitations, stating that the foetal 
pulse may retain its normal rate notwithstanding the existence of severe 
intracranial hemorrhage, while in other cases, in which delivery has 
been effected on account of a very slow heart beat, the child presents 
no signs of asphyxia or of any other abnormality. Notwithstanding 
these generally recognized limitations, the foetal heart rate constitutes 
the most available means of obtaining information concerning the condi¬ 
tion of the child, and should be counted occasionally during the first stage 
of labor, and at intervals of 30 minutes during the second stage. To 
neglect of this latter precaution can be attributed the death of many 
children, which otherwise could have been saved. 

In vertex presentations another characteristic sign of impending 
asphyxia is the escape of meconium. This is due to relaxation of the 
sphincter ani muscle induced by faulty aeration of the blood. Accord- 
whenever the amniotic fluid presents a yellowish-green appearance 
and contains flakes of meconium, we may conclude that the child is in 
danger, and that the only hope for its safety lies in prompt delivery. 
In breech presentations, of course, this symptom is without significance, 
as it is a purely mechanical result of pressure applied to the abdomen 
of the foetus. 





ASPHYXIA 


969 


Especially in difficult breech extractions, when delay is experienced 
in delivering the head, signs of asphyxia may appear in a child which 
was apparently in excellent condition before the operation. In such 
circumstances the finger in the child’s mouth can readily appreciate the 
fact that vigorous inspiratory movements are being made. A similar 
phenomenon may occasionally be observed in vertex presentations, when 
the head is arrested on the pelvic floor, the movements of the mouth 
i being felt or seen through the thinned-out perineum. 

Very exceptionally the child may not only make inspiratory efforts, 
but actually give utterance to sounds in uterovagitus uterinus. For 
the production of this phenomenon it is essential that air gain access 
to the foetus, its entrance into the uterus sometimes resulting from 
the introduction of the hand or instruments. A very characteristic 
example of this phenomenon has been recorded by Bucura, who has 
collated the literature bearing upon the subject up to 1904. 

After delivery the asphyxiated child may present one of two appear¬ 
ances —asphyxia pallida or asphyxia livida. In both respiration is in 
abeyance or occurs only in gasps, while the heart beats slowly and 
feebly. In the former the surface of the body is pale and cold, the 
extremities hang limp, and the child fails to respond to the usual external 
stimuli. In the latter, on the other hand, it presents a congested or 
livid appearance, which is usually attributed to overdistention of the 
right heart and the inferior vena cava. This form of asphyxia is usually 
more amenable to treatment than the pallid variety, which is frequently 
associated w r ith cerebral injury. 

Prognosis.— Asphyxia neonatorium is always serious. The prognosis 
is relatively favorable when the condition is due to mechanical interfer¬ 
ence with the placental circulation, but is far less so when it results 
from injuries to the brain, such as intracranial hemorrhage, fractures, 
or depressions of the skull. 

Treatment. —Normally, the child should make its first inspiratory 
movement a few seconds after it emerges from the vulva. If this does 
not occur, the feet being grasped by the fingers of one hand and the 
child suspended with its head downward, its body should be slapped 
gently with the other. If this maneuver does not prove immediately 
successful, and particularly if attempts at respiration are associated 
with a gurgling sound, a finger, covered with gauze, should be passed 
to the back of the pharynx for the purpose of removing any foreign 
material which may interfere with the free access of aii to the laryngeal 
opening. Ordinarily, if the child is not deeply asphyxiated, these 
measures will bring about the desired results. 

In some instances, however, more radical measures w ill lie found 
necessary. In such cases the cord should be ligated and cut through, 
and the child immersed in hot water, with only its head protruding, 
and rubbed vigorously. As soon as it takes on a pink color, it should 
be immersed in cold water, and usually upon coming in contact with 
it, an inspiratory movement is made and it begins to cry. If thoio is 
any reason to believe that the trachea and larger bronchi contain mucous 
or amniotic fluid, a small, soft-rubber catheter should be introduced into 






970 SUDDEN DEATH DURING LABOR 


Fig. 681. 


the larynx and the offending material re 
moved by suction exerted by the obstetri 
cian, or by the employment of a Ribemont 
Dessaignes insufflator. 

If these measures do not lead to th 
establishment of respiration, the chib 
should be wrapped in a piece of blanke 
or flannel to prevent too rapid cooling, an< 
laid upon a table or chair, the head beinj 
allowed to hang over the edge. The tip o 
the tongue is then grasped by a small pai 
of artery forceps and drawn forward a; 
far as possible and then allowed to recede 
the maneuver being repeated at regula 
intervals 10 or 12 times to the minute 
After the first few tractions an inspiratory 
movement usually follows, after whicl 
respiration goes on regularly, upon tht 
principle that traction upon the tongu< 
irritates the fibers of the superior laryngeal 
glossopharyngeal, and lingual nerves, whicl 
in turn give rise to a reflex stimulatior 
of the phrenic nerves with consequent con 
traction of the diaphragm and the inter¬ 
costal muscles. Generally speaking, it if 
a most effective measure, and the prognosif : 
becomes extremely gloomy if its employ¬ 
ment is not attended by satisfoctory resultf 
within a few minutes. Occasionally, its i 
efficiency may be heightened by practicing 
it with the child immersed in a hot bath 
Before, however, despairing of saving 
the child's life recourse may be had tc 
Schnitzels method. In this maneuver, as- 
shown in Figs. 682 and 683, the child is 
seized by both hands in such a manner 
that the index fingers of the operator lie 
ruder its axillae, the thumbs over the 
thorax, while the palmar surfaces of the 
remaining fingers are applied to its back, 
the head at the same time being fixed by 
the balls of the thumbs. The obstetrician 
stands with his legs apart and at first al¬ 
lows the fcetus to hang down between them, 
he then slowly carries the child over his 
head in such a manner that the legs fall 
toward its face, so that the body becomes 
sarply flexed, after which he brings it back to its original position. 
Ihe maneuver is repeated 5 or 6 times a minute. The rationale of the 


Fig. 682. 


Figs. 681, 682. —Schultze’s 
Method of Resuscitation. 









ASPHYXIA 


971 


method is readily appreciated: the thorax is markedly compressed when 
the child is elevated, and expanded when it is lowered, the two positions 
favoring expiration and inspiration respectively. 

Some idea of its efficiency may be gained by the fact that, when 
it is practiced upon a dead child, air can be distinctly heard to enter 
and leave the lungs with each movement, and Schultze, in 1911, still 
contended that it is the most efficient method at our disposal. The 
procedure, howevei, is not without disadvantages; for, if too violently 
employed, it sometimes gives rise to fracture of the clavicles or ribs, 
and occasionally to rupture of the liver or other serious lesions of the 
internal organs. Moreover, in view of the no small degree of violence 
associated with its use, the maneuver is contra-indicated when the 
clavicle or humerus has been fractured during a difficult extraction, 
inasmuch as the free ends of the bones are liable to cause serious injury 
to the soft parts. 

Byrd, in 1874, and Dew, in 1893, suggested a convenient substitute 
for Schultze’s method. The latter recommended that the child be 
grasped with the left hand, allowing the neck to rest between the thumb 
and forefinger so that the head falls far backward; while the right hand 
grasps the legs in such a way that the right knee rests between the 
thumb and forefinger, and the left between the fore and middle fingers, 
with the back of the thighs resting upon the palm of the hand. In 
order to bring about inspiration the child is gently bent backward, while 
the reverse movement compresses the thoracic contents and causes ex¬ 
piration. Dew^ claims that this method is quite as efficient as that of 
Schultze, and has the additional advantage that it is less likely to cause 
injury to the child, and is much less fatiguing to the operator. 

Recently several patented devices have been put upon the market 
by means of which it is possible to pump into and withdraw from the 
lungs of the asphyxiated child regulated quantities of oxygen gas or 
atmospheric air. It is claimed that they offer the most, efficient means 
of stimulating respiration. In my experience, however, they are not 
superior to the methods generally employed. At the same time they 
are bulky and unnecessarily expensive, and are being advertised in so 
objectionable a manner that self-respecting practitioners should hesitate 
to advocate their employment. 

As asphyxia livida is associated with over-loading of the right side 
of the heart, it is sometimes advisable to loosen the ligature at the free 
end of the cord so as to allow the escape of 15 cubic centimeters of blood. 
In obstinate cases some authorities recommend the injection of a few 
drops of whiskey or ether, but I have not observed beneficial results 
following it. 

When the asphyxia is the result of a depressed fracture of the skull, 
the depressed portion should be elevated in the hope of removing the 
source Of compression. Such an operation, however, should be attempted 
only when the heart still continues to beat strongly, though slowly. 

Efforts at resuscitation should be preserved in as long as the heart 
continues to beat, one method after another being given a trial. The 
necessity for persistence is shown by the fact that successful results are 



972 


SUDDEN DEATH DURING LABOR 


occasionally obtained after trials lasting for thirty to sixty minutes, or 
even longer. 

SUDDEN DEATH DURING OR SHORTLY AFTER LABOR 

Ordinarily, death occurring during labor, or in the first few hours 
immediately following it, is the result of some one of the abnormalities 
to which allusion has already been made, particularly pulmonary em¬ 
bolism, acute edema of the lungs, apoplexy complicating eclampsia, or 
acute anemia the result of postpartum hemorrhage, placenta previa, 
premature separation of the normally implanted placenta, or rupture of 
the birth canal. This subject was discussed in detail by E. P. Davis 
in 1905, to whose article the student is referred for an extensive bibli¬ 
ography. 

In rare instances incomplete rupture of the uterus is unattended by 
symptoms at the time of its occurrence, the blood slowly accumulating 
between the folds of the broad ligament with a gradual development of 
symptoms of shock. A subperitoneal hematoma formed in this way is 
liable to rupture into the peritoneal cavity at any time within the first 
forty-eight hours after delivery and lead to sudden death. 

Moreover, a woman in labor, or during the puerperium, may die 
suddenly from the effects of any condition which would give rise to a 
similar outcome under other circumstances. Thus, cases have been re¬ 
ported in which the fatal termination was due to rupture of an aortic 
or cardiac aneurism, hemorrhage from a gastric ulcer, or other accidents. 
Van der Velde has reported a case of a fatal retroperitoneal hemorrhage 
complicating an acute pancreatitis, while Node and Hines observed 
sudden death during labor following the rupture of an aneurism of the 
splenic artery. 

In the chapter dealing with the Pathology of Pregnancy reference 
was made to the consequences of labor in women suffering from valvular 
lesions of the heart, particularly stenosis of the mitral orifice. Less 
frequently sudden death may be due to fatty degeneration or to changes 
in the myocardium. Such accidents are to be particularly dreaded in 
elderly and corpulent women. 

Shock.—Formerly it was customary to attribute a certain number of 
deaths following labor to shock, which was supposed to occur occasionally 
after prolonged and very painful labors, the incidental loss of rest, 
imperfect nutrition, and mental excitement being looked upon as pre¬ 
disposing causes. In the present state of our knowledge, however, this 
explanation is hardly permissible, since in the majority of such cases 
a carefully performed autopsy will reveal the existence of some condi¬ 
tion sufficiently serious to account for the unfavorable outcome, the most 
common being hemorrhage following injury to the genital tract. 

Syncope.—Faintness is not an uncommon result of exhaustion fol¬ 
lowing prolonged labor, and in neuropathic individuals may occur even 
after an easy and rapid delivery. In rare instances it may be due to 
cerebral anemia resulting from lack of blood in the nervous centers 






SUDDEN DEATH DURING OR SHORTLY AFTER LABOR 973 


following the sudden diminution in the intra-abdominal pressure incident 
to the rapid decrease in the size of the uterus. 

I he faintness usually passes otf rapidly and does not lead to untoward 
results. On the other hand, it ocasionally gives cause for serious alarm, 
the pulse becoming weaker and more rapid and the patient remaining in 
a condition of profound prostration. I have never seen a death from 
this cause, but can recall one patient who caused me the greatest anxiety, 
and who seemed to be in imminent danger for hours. 

Haig Ferguson reports 3 cases of serious exhaustion following labor 
in which he was inclined to attribute the condition to reflex irritation 
recovery, is to be found in the mental condition of the patient, since the 
ployment of Crede’s method of expressing the placenta, the organ being 
grasped laterally instead of anteroposteriorly. 

Profound Mental Depression. —In rare instances the only apparent 
explanation for death, or for a profound collapse which eventuates in 
recovery, is to be found in the mental condition of the patient, since the 
most careful examination, both at the bedside and at autopsy, may fail 
to reveal the slightest abnormality. 

I recall a case in my own practice which apparently belongs in this 
category. The patient, who was unhappily married, had already passed 
through two difficult labors. When I saw her, in the latter part of the 
first stage of her third labor, she was about the room. Just before going 
to bed at the beginning of the second stage she asked the nurse and 
me to witness her will, as she said she felt sure she would not survive. 
The labor was rapid and uneventful, the placenta coming away spon¬ 
taneously. An hour later, on approaching the bed to take leave of the 
patient, I was struck with her haggard appearance. Fearing the possi¬ 
bility of concealed hemorrhage I at once aplied my hand over the uterus 
and found it tightly contracted, while the pulse was of excellent quality. 
Without any apparent reason, and in spite of energetic stimulation, 
the patient grew slowly worse, the pulse becoming rapid and weak, the 
eyes sinking back in their sockets, and the face assuming a drawn and 
Hippocratic expres-don. 

Thorough examination failed to reveal the slightest cause for the 
condition. The hand introduced into the uterus could find no trace of 
rupture. Eight hours after delivery I requested a colleague to see her 
in consultation, but he also was unable to offer any explanation. It then 
occurred to me that the condition might possibly be the result of her 
morbid forebodings, and acting upon that supposition I administered a 
large dose of morphin hypodermically, which was promptly followed by 
sound sleep, a marked improvement in the character of the pulse, and 
some rapid change for the better in the general appearance. Upon 
awakening a few hours later the patient felt very comfortable and made 
an uninterrupted recovery. 

Pulmonary Embolism. —This accident, usually noted only later in the 
puerperium, but occasionally occurring shortly after labor, is due to the 
detachment of a small particle of thrombus situated in a uterine or 
pelvic vein or elsewhere, which is carried to the right side of the heart 
and leads to more or less complete occlusion of the pulmonary artery. 




974 


SUDDEN DEATH DURING LABOR 


It is usually associated with infective or thrombotic processes elsewhere 
in the body, though it may occur in women who were apparently per¬ 
fectly well. Davis considers it the most frequent cause of sudden death 
in the absence of definite disease. Under such circumstances the patient 
complains of intense and sudden precordial pain, becomes livid in ap¬ 
pearance, and presents symptoms of profound dyspnea and eventually 
of air hunger. These embolisms, however, are not always fatal, a certain 
proportion of the patients recovering. 

The treatment is purely palliative. The woman should be placed in 
the recumbent position, kept in absolute rest, and given the necessary 
sedatives, particularly morphia and bromide of potassium. When indi¬ 
cated, inhalations of oxygen may prove beneficial. 

Entrance of Air into the Uterine Sinuses. —Occasional cases of death 
following intra-uterine manipulations in women suffering from placenta 
previa or rupture of the uterus have been attributed by certain authori¬ 
ties to the entrance of air into the uterine sinuses, whence it is carried 
to the heart. The exact cause of death is not understood, some holding 
that the air bubbles enter the coronary arteries, and others that the right 
heart, being unable to rid itself of them, becomes paralyzed as a result 
of its fruitless efforts. The symptoms are analogous to those following 
pulmonary embolism. Cases of this character have been reported by 
Olshausen, Lesse, Perkins, Roger, and others. 

That such a condition occasionally occurs is clear from the fact that 
cases have been reported in which sudden death followed the pumping 
of air into the pregnant uterus for the purpose of producing abortion. 
On the other hand, it is probable that its frequency has been over¬ 
estimated, as most of the cases which have come to autopsy, and which 
were supposed to demonstrate such a possibility, are open to another 
and far more reasonable explanation. Thus, Dobbin was able to 
demonstrate the presence of Bacillus aerogenes capsulatus in the tissues 
from one of Perkin’s cases, in which the presence of air hubbies in the 
blood-vessels had been regarded as satisfactory evidence as to the cause 
of death. Wendeler had a similar experience, and it would therefore 
seem permissible to regard with skepticism. all cases of supposed air 
embolism unless death had occurred almost instantaneouslv, or in which 
careful bacteriological investigation had demonstrated the absence of gas 
bacilli. 

Acute Dilatation of the Stomach. —Very exceptionally following op¬ 
erative as well as spontaneous labor, the patient may pass into a con¬ 
dition of profound shock, associated with symptoms of acute dilatation 
of the stomach—great distention of that organ and the expulsion of 
immense quantities of dark fluid vomitus—and death may follow, or 
recovery ensue, just as in the similar condition, which is so well known 
to surgeons. 

I have encountered the complication upon one occasion. In this 
instance a healthy woman, one hour after the completion of a relatively 
easy spontaneous labor, passed into a condition of profound shock and 
hovered between life and death for 24 hours. The first manifestation 
was a change in the character and rate of the pulse, but the true con- 





LITERATURE 


975 


dition was not suspected until the onset of the characteristic vomiting 
a few hours later. 

Audebert, in 1912, was able to collect 12 cases from the literature. 
As labor was spontaneous in three of them, he was inclined to attribute 
the condition to paralysis of the stomach due to the action of chloro¬ 
form. As my patient received only a minimal amount of the drug, I 
sought the etiological factor in an arterioduodenal occlusion following 
the acute diminution in the bulk of the abdominal contents, incident to 
the sudden decrease in the size of the uterus. Whatever the cause mav 

%j 

be, the condition is most serious, and now that attention has been called 
to its possibility it should be recognized as one of the causes for sudden 
death following delivery. The best results are obtained by placing the 
patient in an inclined position, with the head considerably lower than 
the feet, emptying the stomach by a suitable tube, and stimulating 
according to the exigencies of the case. 

Post Mortem Delivery.—In the literature, which has been carefully 
searched by Aveling and Reimann, a number of cases are recorded in 
which spontaneous birth of the child took place some hours or days 
after the death of the mother. Moreover, delivery sometimes occurs 
after burial, and, when the body has been exhumed for some reason, 
two individuals instead of one have been found in the coffin. These 
are instances of the so-called “coffin birth.' The phenomenon is usually 
observed in multiparous women in whom the birth canal is markedly 
relaxed, and is attributable to a marked increase in the intra-abdominal 
pressure produced by putrefactive changes, though certain • authorities 
believe that rigor mortis of the uterine musculature is the causative 
factor. 

LITERATURE 

Audebert. La dilatation aigue de l’estomac chez les accouchees. Annales de 
gyn. et d’obst., 1912, ix, 92-104. 

Aveling. On Post-mortem Parturition, with References to 1 orty-four Cases. 

Trans. London Obst. Soc., 1873, xiv, 240-258. 

Baumm. Etwas iiber kindliehen Herztone. Archiv. f. Gyn., 1917, cvii, 353-366. 
Bucura. Vagitus uterinus. Zentralbl. f. Gyn., 1904, xxviii, 129-1.>6. 

Byrd. A Speedy Method in Asphyxia. The Obst. Jour, of Great Britain and 

Ireland, 1874, i, 65-69, Amer. Supplement. 

Davis. Sudden Death during or immediately after the Termination of Picg- 
nancy. Trans. Am. Gyn. Soc., 1905, xxx, 345-366. 

Dew. Establishing a New Method of Artificial Respiration in Asphyxia Neona¬ 
torum. Medical Record, Mar. 11, 1893. 

Dobbin. Bemerkungen zu den Arbeiten von Schnell, Wendeler, und Goebel: 
Ueber einen Fall von Gasblasen im Blute einer nach Tympama uteri gestor- 
benen Puerpera. Monatsschr. f. Geb. u. Gyn., 1897, vi, 375-o79. 

Ferguson. On a Variety of Post-partum Shock, its Nature, Cause, and Preven¬ 
tion. Edinburgh Med. Jour., 1899, xxxv, 32-41. 

Laborde. Les tractions rhythmees de la langue, moyen rationnel et puissant de 
ranimer la fonction respiratoire et la vie. Paris, 1894. 

Lesse. Ein weiterer Fall von Luftembolie bei Placenta praevia. Zeitschr. f. Geb. 

u. Gyn., 1896, xxv, 184-191. 



976 


SUDDEN DEATH DURING LABOR 


Nodes and Hines. Fatal Rupture of an Aneurysm of the Splenic Artery immedi¬ 
ately after Labour. Trans. London Obst. Soc., 1900, xlii, 305-310. 

Olshausen. Ueber Lufteintritt in die Uterusvenen. Monatsschr. f. Geburtsk., 
1864, xxiv, 350-374. 

Perkins. Air Embolism, etc. Boston Med. and Surg. Jour., 1897, cxxxvi, 154-156. 

Reimann. Ueber Geburten nach dem Tode der Mutter. Arckiv f. Gyn., 1877, xi, 
215-255. 

Roger, fltude clinique sur la phenomene de 1’entree de Fair par les sinus uterins 
dans l’etat puerperal. These de Paris, 1899. 

Schultze. Ueber die beste Methode der Wiederbelebung scheintodt gebo.rener 
Kinder. Jenaische Zeitschr. f. Med. u. Naturwissensch., 1866, iii, Heft 4. 

Der Scheintod Neugeborener. Jena, 3871. 

Zur Behandlung des Scheintodes Neugeborener. Zeitschr. f. Geb. u. Gyn., 1911, 
lxviii, 591-596. 

Van der Velde. Ein Fall von todtlicher Pancreasblutung, etc. Ref. FrommeUs 
Jahresbericht, 1898, 764. 

Wendeler. Uebe.r einen Fall von Gasblasen im Blute einer nach Tympania uteri 
gestorbenen Puerpera. Monatsschr. f. Geb. u. Gyn., 1896, iv, 581-583. 





SECTION VIII 

PATHOLOGY OF THE PUERPERIUM 
CHAPTER XLIII 

PUERPERAL INFECTION 


Under the general heading of “puerperal infection” are now included 
all the various morbid conditions which result from the entrance of in¬ 
fective microorganisms into the female generative tract during labor or 
the puerperium. The older term, “puerperal fever,” is at once too vague 
and misleading, and for many reasons should be discarded. In the first 
place it suggests the old idea of the essentiality of the affection so 
strongly urged by the late Fordyce Barker, and takes no account of the 
various etiological factors which may be concerned. Moreover, it em¬ 
phasizes the febrile phenomena of the affection, instead of laying stress 
upon its infectious nature and the consequent responsibility of the ob¬ 
stetrician and his assistants. Again, “puerperal septicemia” and “puer¬ 
peral sepsis,” which are often used as synonymous terms, are hardly less 
satisfactory, inasmuch as in many instances the infection results in 
perfectly localized inflammatory processes, to which such terms cannot 
be applied without violating the established rules of diction. 

It is probable that puerperal infection has occurred almost as long 
as children have been born, and passages in the works of Hippocrates, 
Galen, Avicenna, and many of the old writers clearly have reference to 
it. As early as 1676 Willis wrote on the subject of febris puerperarum, 
but the English term “puerperal fever” was probably first employed by 
Strother in 1718. 

The ancients regarded the affection as the result of retention of the 
lochia, and for centuries this explanation was universally accepted. In 
the early part of the seventeenth century Plater showed that it was 
essentially a metritis, and was followed in the next century by Puzos 
with his milk metastasis theory. From the time of Plater, until Sem- 
melweiss proved its identity with wound infection, and Lister demon¬ 
strated the value of antiseptic methods, all sorts of theories were sug¬ 
gested concerning its origin and nature, which are comprehensively dealt 
with in the monographs of Eisenmann, Silberschmidt, and Burtenshaw. 

Bacteriology. —Although Charles White (1793) and Alexander 
Gordon (1795) clearly recognized the contagious nature of puerperal 
infection, and many other British observers had vague ideas upon the 
subject, it was not until the middle of the nineteenth century that such 

977 





978 


PUERPERAL INFECTION 


views were strongly urged. In 1843 Oliver Wendell Holmes read a 
paper before the Boston Society for Medical Improvement, entitled “The 
Contagiousness of Puerperal Fever,” in which he clearly showed that at 
least the epidemic forms of the affection could always be traced to the 
lack of proper precautions on the part of the physician or nurse. Four 
years later Semmelweiss, then an assistant in the Vienna Lying-in 
Hospital, began a careful inquiry into the causes of the frightful mor¬ 
tality attending labor in that institution, as compared with the com¬ 
paratively small number of women succumbing to puerperal infection 
when delivered in their own homes. As a result of his investigations 
he concluded that the morbid process was essentially a wound infection, 
and was due to the introduction of septic material by the examining 
finger. Acting upon this idea he issued stringent orders that the physi¬ 
cians, students, and midwives should disinfect their hands with chlorin 
water before examining parturient women. In spite of almost imme¬ 
diate surprising results—the mortality falling from over 10 to about 1 
per cent.—his work, as well as that of Holmes, was scoffed at by many 
of the most prominent men of the time, and his discovery remained 
unappreciated until the influence of Lister’s teachings and the develop¬ 
ment of bacteriology had brought about a revolution in the treatment of 
wounds. 

It is now universally acknowledged that puerperal infection is wound 
infection, and is due to the invasion of the generative tract by various 
pyogenic bacteria. The principal microorganisms concerned are the 
following: 

(a) Streptococcus .—As early as 1865 this organism was discovered 
by Mayrhofer in the tissues of women who had died during the puer- 
perium, and confirmatory observations were made by Coze and Feltz, 
Recklinghausen, Waldeyer, Klebs, Orth, and Heibig. Pasteur, in 1880, 
however, was the first to cultivate streptococci from cases of puerperal 
infection, and he called them “chapelets en grains.” He was assisted by 
Doleris, who showed that they were the usual infectious agents, but that 
other bacteria were sometimes concerned. These researches were soon 
confirmed by Lomer, Bumm, Doderlein, Winter, Widal, and by all sub¬ 
sequent observers, so that the streptococcus is now believed to be the 
usual cause of the epidemic and fatal forms of puerperal infection. 

In 1903, Schottmiiller showed when streptococci, obtained from seri¬ 
ously ill patients, were grown upon blood-agar that each colony became 
surrounded by an area of hemolysis, which w r as lacking in the sapro¬ 
phytic varieties of the organism. His findings were confirmed by 
Fromme, Gonnet, and others, so that it was believed for a time that three 
types could be differentiated—streptococcus pyogenes, streptococcus 
mitior or gracilis, and streptococcus mucosus. It was held that the first, 
which is always hemolytic, was concerned in the production of virulent 
infections, while the other two varieties, which are lacking in hemolytic 
properties, were either saprophytic or only slightly pathogenic in char¬ 
acter. 

I he work of Natwig, Lea and Sidebotham, and others has shown 
that these conclusions are too sweeping, and that while hemolytic strep- 




BACTERIOLOGY 


979 


tococci are frequently highly virulent, they are not always so. Further¬ 
more, the non-hemolytic variety is occasionally very pathogenic; and, as 
the hemolytic property may either be lost or accentuated by various 
cultural methods, it would appear inadvisable to consider its existence as 
characteristic of a distinct species of streptococcus. 

Although Kronig, myself, and others had previously isolated an 
anaerobic streptococcus, it was not until 1910 that Schottmiiller demon¬ 
strated its practical importance. By the use of suitable anaerobic culture 
media, the latter was able to isolate it from many cases, and concluded 
that it was more frequently concerned in the production of puerperal 
infection than the ordinary aerobic variety. As the organism produces 
large amounts of sulphuretted hydrogen he designated it as the strep¬ 
tococcus putridus. Bondy, Briitt, and others have made similar ob¬ 
servations, but it appears that Schottmiiller’s conclusions were too 
sweeping. 

(b) Staphylococcus .—Further investigation gradually demonstrated 
the fact that the streptococcus is not necessarily the only organism which 
may be concerned, but that most of the pus producers, which give rise 
to wound infection in other parts of the body, may likewise at times be 
the exciting factors. 

Brieger, in 1888, reported that he had demonstrated Staphylococcus 
aureus in five fatal cases. Doleris stated, in 1880, that he had been 
able to cultivate in pure culture cocci arranged in groups or bunches, 
but it was not until 1894 that he stated definitely that they were 
staphylococci. 

The statement made by Fehling and Haegler that staphylococci 
usually give rise to mild forms of infection has not been borne out by 
the observations of other investigators. Occasionally mixed infections 
with the streptococcus or colon bacillus are observed. Staphylococcus 
aureus is the variety usually observed in puerperal infection, the albus 
and citreus playing little or no part in its production; while Rosowsky 
has shown that an anaerobic form is occasionally concerned. 

(c) Gonococcus .—Although clinicians had long suspected that gonor¬ 
rhea frequently plays a part in the production of puerperal inlection, 
Kronig was the first to adduce bacteriological proof of its action. In 
1893 he reported 9 cases of mild infection, in which he was able to 
obtain pure cultures of gonococci from the uterine lochia. In a latei com¬ 
munication he stated that he had been able to cultivate the same oigan- 
ism from the discharges of 50 out of 179 febrile puerperal patients, 
most of whom recovered spontaneously; while we have found it in 
approximately nine per cent, of our febrile patients. 

Kronig’s experience has been confirmed by all subsequent investi¬ 
gators, and Taussig, and Stone and McDonald state respectively that 
one-sixth to one-tenth of all rises of temperature in the puerperium aie 
the result of gonorrheal infection. As far as I am a^aie Foulerton and 
Bonney are the only recent writers who have not had a similar expeiknee. 
Furthermore, I have repeatedly demonstrated the gonococcus in the 
tissues of cases of decidual endometritis, and others have made similar 
observations. As a rule, gonorrheal infection in the puerperium pursues 







980 


PUERPERAL INFECTION 


a favorable course, but occasionally fatal septicemia may result, as in 
two of my cases reported by Harris and Dabney, and J. T. Smith. 

( d ) Bacillus Coli Communis. —In my first article upon puerperal 
infection (1893), it was stated that von Franque had cultivated the 
colon bacillus from a case of puerperal infection, and the belief was 
expressed that it would be demonstrated more frequently in the future. 
Time has amply verified this prediction, and there are now on record 
a long series of such cases. A priori, this is what would be expected 
when one takes into consideration the proximity of the genital tract to 
the rectum, and the enormous numbers of colon bacilli which are evacu¬ 
ated. As Vignal has shown that 1 decigram of feces contains about 
20,000,000 colon bacilli, it is evident that the examining finger can 
hardly avoid contamination with them if it comes in contact with an 
imperfectly disinfected perineum. 

Gebhard demonstrated their presence in 7 cases of tympania utero, 
either alone or in combination with other organisms, and Galtier states 
that it is the organism most frequently concerned in the production of 
that condition. 

Ordinarily pure colon infections are relatively benign in character, 
but occasionally, as shown by Lenhartz and others, fatal septicemia may 
ensue. In most serious colon bacillus infections the organism is asso¬ 
ciated with the streptococcus, and it appears that such a combination 
tends to augment the virulence of both species of bacteria. 

( e) Bacillus Diphtheriae. —Formerly it was believed that the diph¬ 
theritic deposits upon the vagina and the interior of the puerperal uterus 
were due to the streptococcus alone, and were in no way connected with 
true diphtheria. That this is not always the case, however, has been 
shown by the observations of Nisot, Bunnn, Lop. myself, and others, 
who have cultivated the Klebs-Loeffler bacillus from the diphtheritic 
membrane in the vagina, the affection yielding promptly to the use of 
the antidiphtheritic serum. Gide, in 1911, was able to collect 42 such 
cases. Wauschkuhn. states that such infections are not uncommon, and 
that in a series of 200 apparently healthy women he found that diph¬ 
theria bacilli were carried nearly as frequently in the vaginal secretion 
as in the tonsils. 

(/) Bacillus Aerogenes Capsulatus (Gas Bacillus).—The gas bacillus 
pf Welch is occasionally concerned in puerperal infection, especially 
when it follows criminal abortions. In 1896 I observed an instance of 
the kind, which was reported by Dobbin. Briefly stated, the case was 
as follows: An outdoor patient had been in labor for several days under 
the care of a midwife. When she came into our hands she was pro¬ 
foundly infected and the head of a macerated child was found firmly 
engaged in the contracted superior strait, the uterus being in a state of 
tetanic contraction. A fetid, dark-colored discharge, which contained 
many gas bubbles, was escaping from the vagina with a crackling sound. 
Delivery was effected by carniotomy, and death occurred the next day. 
Mithin a few hours the patient*s body had nearly doubled its size, 
as the result of the development of gas in the subcutaneous tissues. 
Similar changes were observed in the foetus and in the placenta, in both 


BACTERIOLOGY 


981 


of which, as well as in the uterine lochia, the presence of the gas bacillus 
was demonstrated. Unfortunately no autopsy was allowed upon the 
mother, and we were therefore unable to say to what extent the or¬ 
ganisms had penetrated into her tissues. 

Following this, many well-authenticated instances of infection with 
this organism have been reported, and the entire literature upon the 
subject was exhaustively reviewed by Welch in 1900, Fraenkel in 1904, 
Heinricius in 1908, and by Heynemann in 1911. Little, in 1905, re¬ 
ported ten cases in which it had been isolated in our service, and pointed 
out that in all probability the organism was identical with the “vibrion 
.septique” of Pasteur, as well as with Bacillus perfringens described by 
various writers. In only one of our cases did the bacillus occur in pure 
culture, while in the others it was associated with various bacteria— 
■particularly with streptococcus. 

As a rule, the gas bacillus exists merely as saprophyte upon dead 
material, and does not invade the deeper tissues until shortly before or 
just after death, but in one of my patients it gave rise to a true septi¬ 
cemia. Accordingly, the prognosis is usually favorable when the organ¬ 
ism occurs in pure culture, but becomes very serious when it is asso¬ 
ciated with the streptococcus, as it would seem that such an association 
tends to augment the virulence of both organisms. According to Welch, 
its presence in the puerperal uterus may give rise to emphysema of the 
fcetus, endometritis, physometra, emphysema of the uterine wall, or 
gas sepsis. Moreover, it is important to remember, as was first pointed 
out by Welch and Dobbin, that the gas bubbles found in the blood 
vessels of women supposed to have perished from “air embolism” are 
frequently the product of the bacillus in question. 

( g) Bacillus Typhosus .—In 1898 Dobbin and I isolated Bacillus 
j typhosus. Streptococcus, Staphylococcus aureus, and an unidentified 

anaerobic gas-producing bacillus from the uterine lochia of a Bohemian 
woman who was admitted to the Johns Hopkins Hospital on the fifth 
day of the puerperium with high fever. Her blood gave the character¬ 
istic Widal reaction, but all the usual symptoms of typhoid fever were 
absent. The temperature fell to normal on the thirteenth day, and did 
not rise again. We were inclined to believe that the bacilli were intro¬ 
duced into her uterus by the midwife, along with other organisms, since 
she was delivered upon the same bed upon which her husband had died 
of typhoid fever a few days previously. In a somewhat similar case 
reported by Blumer, in which the autopsy revealed an unsuspected 
typhoid fever, the presence of typhoid bacilli in the lochia should not be 
regarded as evidence of puerperal infection, but rather of typhoid septi¬ 
cemia. 

(h) Pneumococcus .—In rare instanses this organism may be found 
in the vaginal secretion of apparently healthy pregnant women, and 
may give rise to puerperal infection, which is particularly liable to 
eventuate in peritonitis. Foulerton and Bonney, and Natwig have re¬ 
ported cases in which it was found, and Hornung has collected the 
literature upon the subject up to 1920. 

Occasionally the presence of pneumococci in the uterine lochia is 




982 


PUERPERAL INFECTION 


merely a manifestation of a general septicemia originating from a focus 
outside of the generative tract, as reported by Czemetschka, and Burch- 
hardt, as well as by Johnston and Morgan from our clinic and others. 
Bondy has pointed out how difficult it may be in a given case to deter¬ 
mine whether such a finding should be regarded as evidence of external 
infection or of mere transportation by the blood stream. 

Still more occasionally the pneumobacillus of Friedlander may be 
isolated, as was shown by the observations of Howard, Fromme, Chine, 
and others. 

(i) Bacillary Infections. —Perkins, Charrin, and others have recorded 
cases in which the bacillus pyocyaneus was the infectious agent. More¬ 
over, isolated observations of Fraenkel, Doleris, Widal, Mixius, Golds- 
cheider, Bunim, and others tend to show that certain cases of fatal 
infection may be due to unidentified bacilli with whose properties we are 
as yet unacquainted. Moreover, routine bacteriological examination of 
the uterine lochia in a considerable proportion of cases of puerperal in¬ 
fection clearly shows that various bacteria with which we are as yet 
unfamiliar may take part in the process. Thus, I have seen a case of 
phlegmasia alba dolens in which the infectious agent was a short, thick, 
anaerobic bacillus. 

(;) Sapremia .—Besides the cases in which the infection is due to the 
growth and extension of microorganisms within the body, there is a 
large group in which the symptoms are due to the absorption of toxins 
produced by bacteria which do not invade the uterine tissues nor make 
their way into the blood current. To this form of infection Matthews 
Duncan applied the term “sapremia.” It is usually thought to be due to 
putrefactive organisms with whose properties we are as yet almost 
totally unfamiliar. 

NTo doubt the term has been greatly abused, and many cases have 

been included under it which were reallv due to infection with the ordi- 

*/ 

nary pyogenic organisms. This statement has been borne out by the 
observations of Bumm, who found streptococci in 8 out of 11 cases which 
were thought to present the clinical picture of sapremia. As von 
Pranque obtained similar results, he concluded that sapremic fever 
should be diagnosed only after an accurate bacteriological examination 
of the uterine lochia has demonstrated the absence of pyogenic 
organisms. 

The causative saprophytes are usually anaerobic, and consequently do 
not grow on the usual culture media. Many of them are gas producers, 
and thereby cause the frothy, ill-smelling secretion which is so charac¬ 
teristic of these cases. Undoubtedly various bacteria may be concerned 
in its production, though only a few have as yet been isolated. Thus, 
Sackenreiter, in 1912, was able to isolate the causative factor in 88 per 
cent, of his cases of putrid endometritis, and found the colon bacillus, 
an anaerobic staphylococcus—staphylococcus parvulus, the streptococcus 
putridus, an influenzalike bacillus, various unidentified anaerobic bacilli, 
the gas bacillus and the bacillus pyocyaneus. 

Bacteriological examination of the uterine lochia in a series of 324 
cases of my own, in which the temperature rose to 101° F., or higher, 


BACTERIOLOGY 


981 


during the first ten days of the puerperium, gave the following results : 


Streptococcus alone. 

and bacillus coli. 

1 1 unidentified bacilli. 

bacillus aerogenes capsulatus. 

‘ ‘ gonococcus. 

bacillus aerogenes capsulatus and bacillus 

coli. 

Streptococcus, anaerobic variety. 

staphylococcus, gas and typhoid bacillus. 

“ ‘ ‘ colon bacillus. 

Staphylococcus aureus. 

and gas bacillus. 

albus and gas bacillus. 

“ albus.. 

Bacillus coli communis. 

‘ ‘ and gas bacillus. 

“ lt gonococcus. 

Gonococcus. 


and gas bacillus. 

‘ ‘ bacillus coli. 

‘ £ unidentified bacillus 

< c <( i i 

coccus. 

Bacillus aerogenes capsulatus. 

Unidentified anaerobic bacteria. 


aerobic bacteria. 

Bacillus diphtheriae. 

typhosus. 

Bacteria on cover slip, cultures negative 

Sterile. 

Contaminated. 


60 cases 
9 “ 

7 “ 

5 “ 

4 “ 

3 “ 

3 “ 

1 case 
1 “ 

3 cases 

1 case 
1 “ 

5 cases 
18 “ 

2 “ 

1 case 

29 cases 
1 case 
1 “ 

1 “ 

1 “ 

3 cases 
22 “ 

6 “ 

1 case 
1 “ 

63 cases 
68 “ 

2 <£ 


During the year ending July 14th, 1923, uterine cultures were taken 
from 75 patients in our service, all of whom recovered, and the following 
bacteria were found: 


Streptococcus hemolyticus, alone. 5 cases 

with other bacteria. 3 ‘ ‘ 

non-hemolyticus, alone. 11 “ 

“ ‘ ‘ ‘ i with other bacteria. 9 ‘ 1 

Staphylococcus albus, alone. 1 case 

with other bacteria. 1 “ 

Bacillus coli communis, alone. 2 cases 

‘ ‘ ‘ ‘ ‘ ‘ with other bacteria. 5 “ 

Gonococcus, alone. 6 11 

Saprophytes. 23 “ 

Unidentified bacillus and coccus. 1 case 

Sterile. 8 cases 


Upon tabulating the 67 cases in which the presence of bacteria was 
demonstrated, the percentage incidence was as follows: 


Bacteria 

No. Cases 

Percentage 

Streptococcus, alone or in combination. 

28 

41.8 

Saprophytes. 

23 

34.3 

Bacillus coli, alone or in combination. 

7 

10.4 

Gonococcus . 

6 

8.9 

Various. 

3 

4.5 





67 

99.9 


























































984 


PUERPERAL INFECTION 


Besides the organisms already mentioned, it is not unlikely that 
further research will show still others which may play a part in the 
production of isolated cases of puerperal infection; but, to summarize, 
it may be said that those most commonly concerned are the well-known 
pyogenic organisms (streptococcus, staphylococcus, bacillus coli, gonococ¬ 
cus, and pneumococcus) and the various putrefactive varieties. 

Pathological Anatomy.—The lesions may vary widely even in cases 
clinically similar, and these variations afford a probable explanation for 
the failure of the older authors to appreciate the true nature of the 
affection. Thus, there may be an almost infinite series of gradations 
from a slight membrane covering a small perineal tear to an inflam¬ 
matory process involving the entire generative tract, or extending beyond 
it to the parametrium or peritoneum, and sometimes resulting in a 
systemic infection. In other cases the infectious elements pass through 
the portal of entry with such rapidity that they do not excite local 
lesions, but produce a septicemia which is rapidly fatal—the sepsis 
foudroyante of the French authors. In the majority of cases the mor¬ 
bid process is limited to the endometrium, resulting in a puerperal 
endometritis. In other cases the lesions may be situated in any part of 
the generative tract, more than one region being frequently implicated. 
Thus, at different times we have to deal with a puerperal vaginitis, endo¬ 
metritis, metritis, parametritis, metrolymphangitis, metrophlebitis, sal¬ 
pingitis, oophoritis, peritonitis, pyemia, or phlegmasia alba dolens 
respectively. 

Lesions of the Vulva and Vagina .—In former times the puerperal 
ulcer was of very common occurrence, but with the introduction of 
aseptic methods its frequency has become greatly diminished. 

These ulcers appear on the surface of tears about the vulva and peri¬ 
neum, soon take on a dirty, greenish-yellow appearance, and are bathed 
in a foul-smelling secretion. As the result of necrosis they are some¬ 
times covered by a grayish-white membrane, and on this account were 
formerly designated as “diphtheritic ulcers,” but, except for their ex¬ 
ternal appearance, they have nothing in common with diphtheria. As 
a rule they give rise to very little systemic disturbance, and would fre¬ 
quently pass unnoticed were it not for ocular inspection. 

Puerperal Vagmitis .—Of this there are two forms, the one being 
characterized by general inflammation, the mucosa becoming thickened, 
soft, reddened, and bathed with an abundant purulent secretion. In the 
other type, especially when torn surfaces are present, the vaginal walls 
may be the seat of a pseudodiphtheritic membrane, which may vary in 
extent from a small patch covering a tear to a complete cast of the entire 
vaginal canal. 

Following the recognition of the predominant role played by the 
streptococcus, it was believed for a time that none of the so-called cases 
of diphtheria of the vagina were due to invasion by the Klebs-Loeffler 
bacillus; but the observations of Bumm, NTisot, myself, and others thow 
that the latter organism is occasionally the etiological factor. 

Endometritis .—The most common lesion in puerperal infection is 
an inflammation of the endometrium. When one recalls the condition of 


PATHOLOGICAL ANATOMY 985 

the uterine cavity immediately after delivery, with its bleeding, raw 
surfaces and the large, gaping thrombosed placental sinuses, it becomes 
appaient that pathogenic bacteria introduced during labor can easily 
find entiy. Again, when one considers the mechanism by which the 
decidua is normally removed during the puerperium, one can readily 
see that an ideal culture medium is prepared by Nature for their recep¬ 
tion and propagation. 



Fig. 683.—Uterus from Woman Dying Ten Days after Labor from Streptococcus 

Infection. X V3. 


In puerperal infection the process may be limited to the placental 
site, or may extend over the entire interior of the uterus. When the for¬ 
mer alone is implicated, the organisms are usually found growing into 
the thrombi. They produce comparatively little local reaction, but give 
rise to the thrombophlebitic type of infection, which will be described 
below. On the other hand, when the entire internal surface of the uterus 
is affected, puerperal endometritis results. In this event, the lesions vary 
considerably according to the microorganisms concerned, and still more 
according to their virulence. When the infection is due to a virulent 









986 


PUERPERAL INFECTION 


streptococcus or staphylococcus, the local lesion may be comparatively 
slight, the discharge scanty, and comparatively free from odor (Fig. 
G83). In such cases the process tends to spread rapidly through the 
lymphatics or veins past the uterus, and gives rise to a peritonitis or a 
general systemic infection. On the other hand, when the infection is 
due to streptococci of lesser virulence, and particularly when they are 
associated with colon bacilli, the entire interior of the uterus is converted 
into a sloughing area made up of necrotic material and decidual debris 



Fig. 684.—Uterus from Woman Dying Ten Days after Labor from a Mixed Infec¬ 
tion with Streptococcus and Bacillus Coli. X 2 A. 


and bathed with a foul smelling, bloody, purulent discharge (Fig. 684). 
In some instances ulcerated areas appear, which are coated with fibrin 
and present the clinical picture of diphtheria. This was formerly desig¬ 
nated as diphtheritic endometritis, but, just as in the case of the vagina, 
the condition, as a rule, simply represents a fibrinous exudation, the 
result of intense necrosis. 

When the infection is due to putrefactive bacteria, to the colon bacil¬ 
lus, or to their association with the ordinary pus organisms of slight 
virulence, the process remains limited to the uterus, and results in so- 
called putrid endometritis. In this event large amounts of necrotic 
material may be produced, in which the bacteria lead a saprophytic 
existence, and give rise to a profuse foul-smelling bloody discharge, which 
frequently contains gas bubbles. The amount of necrotic material pro- 



PATHOLOGICAL ANATOMY 


987 


duced is often enormous, and may recur with great rapidity after curet¬ 
ting. Fig. 684 represents a uterus infected with sttreptococcus and 
bacillus coli. The woman succumbed ten days after the birth of the 
child, the uterus having been scraped clean by means of a curette three 
or four days previously. A glance at the drawing, however, shows that 
the entire cavity is filled with necrotic material, which had been repro¬ 
duced in the interval following the curettage. 

Upon studying the microscopical features of puerperal endometritis, 
these differences are still further accentuated. Our original knowledge 



Fig. 685. —Puerperal Endometritis Due 
to Colon Infection, Showing Mark¬ 
ed Development of Leukocytic 
Wall. 



Fig. 686.—Puerperal Endometritis Due 
to Streptococcus Infection, Show¬ 
ing Slight Development of Leuko¬ 
cytic Wall. 


on this point we owe to Bumm and Dbderlein, both of whom have shown 
that there are marked histological differences between the pntnd and 
septic forms, and my own experience has amply confirmed their con¬ 
clusions. In sections through the wall of a uterus the seal of putrid 
endometritis, a thick layer of necrotic material is found lining the 
uterine cavity, embedded in which are large numbers of the offending 
microorganisms. Beneath it is a thick layer of leukocytic infiltration 
the zone of reaction-and, under this again, more or less normal tissue. 
The microorganisms are limited almost entirely to the superficial necrotic 
layer; and although a few may be present in the reaction zone, none 
can be made out in the tissues beneath it thus showing Nature s mode 
of preventing the invasion of the body (Figs. 6So an ')•_ 

Similar pictures are also observed when the infection is due to 


















988 


PUERPERAL INFECTION 


pyogenic organisms possessing only a slight degree of virulence. On tb 
other hand, in septic endometritis, and especially when the organism 
are virulent, a totally different appearance is noted. Although a layc 
of necrotic material containing organisms adjoins the uterine cavity, i 
is usually thinner than in the preceding case. The zone of leukocyti 
infiltration is either lacking or very imperfectly developed, and th 
microorganisms can he observed making their way down through th 
decidua and along the lymphatics of the muscular wall of the uterus ou 
towards its peritoneal surface (Figs. 687 and 688). 


Fig. 688.—Streptococcus Endometritis, 
Showing Invasion of Leukocytic 
Wall. X 800. 

It would appear, therefore, that Nature endeavors to confine the 
microorganisms to the inner surface of the uterus by interposing be¬ 
tween the necrotic layer and the deeper portions a barrier of leukocytic 
infiltration, which acts as an efficient filter when the bacteria are at¬ 
tenuated, but fails to restrain them when they possess a marked decree 
of virulence. 

As has already been pointed out, in a considerable proportion of 
cases the inflammatory process extends into the uterine musculature, and 
theie gnes lise to divers lesions of metritis, which may vary from small 
aieas of leukocytic infiltration to definite abscess formation. As such 






















PATHOLOGICAL ANATOMY 


989 


i multiple abscesses are due to implication of the lymphatics, and, inas¬ 
much as these channels are most numerous beneath the peritoneal cover¬ 
ing of the uterus, such lesions are most abundant in that situation. 

Under the designation metritis dessicans, Garrigues described a vari- 
i e ty severe puerperal infection in which not only the endometrium, but 
: also a varying amount of the muscularis undergoes necrosis, and is ex¬ 
pelled in large shreds or even as a cast of the interior of the uterus. As 
Schmidlechner suggests, it should more properly be designated as 
gangrene of the uterus. 

Peritonitis. —In the majority of cases of puerperal infection which 
end fatally, death is due to peritonitis. As was pointed out when con¬ 
sidering the histological changes in puerperal endometritis, the strepto¬ 
cocci or other infecting agents may rapidly make their way by means 
I of the lymphatics from the interior of the uterus to the peritoneal sur¬ 
face and there give rise to inflammatory changes. This is the usual 
mode of infection, but in rare instances it may be due to the escape of 
pus from the fallopian tubes; though in none of the autopsies which I 
have witnessed has such a mode of origin been observed. Occasionally, 
i peritonitis may follow the rupture of a parametritic or ovarian abscess, 
while in other cases it may result from instrumental perforation of the 
uterus or vaginal culdesac during criminal abortion. 

Salpingitis. —In a small proportion of cases the infectious process 

I extends directly from the uterine cavity to the fallopian tubes, and there 
gives rise to various inflammatory phenomena. Occasionally the sal¬ 
pingitis is due to infection through the lymphatics and not to direct 
extension from the endometrium. In most instances, however, the tubes 
are not involved, and when they are the lesions are more marked at their 
lateral ends, thus indicating that the infection is secondary to the peri¬ 
toneal improvement. Sometimes an oophoritis occurs, the ovaries being 
enlarged to several times their usual size and very edematous. The 
process may stop here or go on to typical abscess formation. The ovarian 
infection is usually due to lymphatic involvement, and may be associated 
with affections of the parametrium. Much more rarely it results from 
direct infection of a ruptured follicle by means of the peritonitic fluid. 

Parametritis. —One of the more frequent complications of uterine 
infection is parametritis. This frequently follows infected tears of the 
cervix, but in other cases is secondary to a puerperal endometritis; in 
either event it is due to the transmission of the microorganisms through 
the lymphatics to the peri-uterine connective tissue. The first effect of 
their invasion is a marked inflammatory edema, with very little or no 
suppuration. In mild cases the process goes no further, but in the 
severer types it rapidly spreads to the surrounding connective tissue and 
eventuates in abscess formation. In more severe cases the inflammatory 
process follows the course of the lymphatics and in many cases the 
abscess dissects the peritoneum off from the anterior pelvic and abdom¬ 
inal wall, and eventually points over Poupart’s ligament. Less fre^ 
quently the process spreads posteriorly beneath the peritoneum, giving 
rise to retroperitoneal phlegmons , which may extend as high as the 
posterior mediastinum. In still another class of cases the bacteria fol- 








990 


PUERPERAL INFECTION 


low the lymphatics in the connective tissue surrounding the greater 
vessels of the thigh, and give rise to a rare form of phlegmasia alba 
dolens, the usual variety being due to the direct extension of a throm¬ 
botic process originating in the uterine veins. 

Pyemia .—The pyemic or thrombophlebitic form usually results from 
the infection of thrombi at the placental site with subsequent develop- 
ment of inflammatory changes in the veins. The thrombosis may be 
limited to a comparatively small area and be entirely within the uterine 
wall, or it may extend beyond the uterus, involving the internal iliac or 
ovarian veins, or both, so that occasionally all venous trunks leading 
from the pelvis are thrombosed as far up as the junction of the renal 
veins with the inferior vena cava. Its mode of production was exhaus¬ 
tively studied by Bardeleben in 1907. By the breaking down of the 
thrombi small particles escape into the circulation and are carried by the 
blood current in various directions, giving rise to endocarditis and 
metastatic abscesses , from which no portion of the body appears to be 
exempt. In this form of puerperal infection, such abscesses may develop 
in any of the internal organs, the synovial surfaces also being frequently 
implicated and giving rise to swellings about the joints, which, if not 
promptly treated, may lead to their complete destruction. In other 
cases blebs or bullae, due to the same cause, appear on the surface of the 
body, and in their contents the offending microorganisms are readily 
demonstrable. Less frequently, detached particles of thrombi may be 
arrested in one of the larger vessels of the lungs and give rise to pul¬ 
monary embolism and almost instantaneous death. When smaller vessels 
are involved the results are not so serious, though the portion of lung 
supplied by them becomes infarcted and gives rise to a secondary pleurisy 
or pneumonia, which may ultimately lead to death. It would appear 
from the observations of Mahler, Breuer, and Richter that a large part 
of the pulmonary affections occurring in puerperal women originate in 
this manner, and in not a few instances the appearance of a localized 
pleurisy may be the first manifestation of serious thrombotic process. 
Most cases of pyemia present comparatively little uterine involvement, 
and death, when it occurs, is due to general exhaustion following a pro¬ 
longed suppurative process. 

Phlegmasia Alba Bolens .—As was pointed out when considering the 
question of parametritis, this affection is sometimes due to the extension 
through the lymphatics of a parametritic process to the tissues sur¬ 
rounding the great vessels of the thigh. As a rule, however, it results 
fiom the extension of a thrombotic process from the pelvic veins; and in 
seveial of my autopsy cases the thrombophlebitis could be traced from 
the uterus to the common iliac veins, whence it extended upward to the 

vena cava and downward through the external iliac to the vessels of 
the leg. 

Occasionally, in cases which recover, the phlegmasia appears to be an 
iso ated process, though it is probably only a part of a much more ex- 
tensive thrombosis. Moreover, it should be borne in mind that even 
widespread thrombosis may give rise to but slight clinical manifestations, 
as, m one of my cases which came to autopsy, the femoral vein and all 





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SECTION THROUGH ENDOMETRIUM IN STREPTOCOCCIC PUERPERAL 

INFECTION. X 1000. 






ETIOLOGY 


991 


its branches were completely occluded, yet careful mensuration was 
necessary to detect any difference in the size of the legs. 

Clinically phlegmasia alba dolens should always be regarded as a 
manifestation of infection; although it is sometimes impossible to dis¬ 
cover its origin. Thus, 

I have seen it develop 
in several instances in 
which the patient had 
not been examined 
v a g i n a 11 y, and in 

i which the first eleva¬ 
tion of temperature oc- 
curred during the 
course of the third 
week, as well as during 
the second half of 
pregnancy in appar¬ 
ently normal women. Fiq< 689 —g ECTION through Thrombosed Pelvic Vein, 
Furthermore, F. C. Showing Streptococci. X 800. 

Goldsborough has de¬ 
scribed a case of complete occlusion of the common iliac, external iliac, 
and femoral veins, which occurred in my service, and was clearly the 
result of pressure. The inference, however, that the process is not of 
infective origin, is not permissible unless the patient comes to autopsy, 
and careful bacteriological examination demonstrates the absence of 



bacteria 

An idea of the frequency of the various lesions in fatal cases of 
puerperal infection may be gained from the following figures of Kneise, 
which were based upon the findings in 89 autopsies: 


t, *i • .. 43 cases 

Peritonitis. 2 a << 

Thrombophlebitis. ^ (( 

Pyemia. y < < 

Parametritis. 2 < < 

Sepsis foudroyante. 

Etiology.—As it has been conclusively demonstrated that the bacteria 
concerned in puerperal infection are identical with those with which we 
are familiar as causing ordinary wound infection, it. must follow that 
puerperal infection is a wound infection resulting from the introduction 
of pyogenic bacteria into the generative tract either before, during, 01 
immediately after labor. In other words, it is usually a direct m no¬ 
tion from without, the bacteria being brought to the woman by the hands, 
instruments, or any other object which may come m contact with her 

SCn ^Srafinfection, then, is contact infection, this conception having 
been first definitely enunciated by Semmelweiss in the following words: 
“I consider puerperal fever, not a single case excepted, as a resorption 
fever, caused by the resorption of a decomposed animal-organic material. 
The first result of the absorption is a change in the blood, and the 
exudations are the result of this change. The decomposed animal- 














992 


PUERPERAL INFECTION 


organic material, which, when resorhed, causes childbed fever, is brought 
to the individual from without in the great majority of cases, and this | 
is infection from without. These are the cases which represent the 
epidemics of childbed fever. These are the cases which can be prevented. 

In the latter part of the eighteenth century puerperal fever began to i 
be considered as a contagious malady in England. This conception ap¬ 
parently originated with Thomas Kirkland, of Ashby, in 1774, but was 
first clearly enunciated in 1795 by Gordon, of Aberdeen, in his treatise 
“On the Epidemic of Puerperal Fever, as it prevailed in Aberdeen from 
December, 1789, to March, 1792 ” In this he gave an account of 77 
cases which he had attended, and, among other things, stated: “It is a 
disagreeable declaration for me to mention that I myself was the means 
of carrying the infection to a great number of women.” 

In this country we are mainly indebted to Oliver Wendell Holmes 
for introducing the conception of the infectious nature of the affection. 
In an article entitled “Puerperal Fever as a Private Pestilence/'" first 
published in 1843, he clearly showed that the epidemic form of the disease 
was preventable, and owed its origin either to the physician or midwife. 
His teachings, however, did not exert the influence which might have 
been expected, mainly because they were opposed by the leading obstetri¬ 
cians of the country, notably Meigs and Hodge, the former stating that 
he preferred to consider the disease as due to the workings of Providence, 
which he could understand, rather than to an unknown infection of 
which he could form no conception. 

For many years the prevalent theory in Europe was that puerperal 
fever was due to miasmatic, telluric, or atmospheric influences. This 
view held its ground for years after the appearance of Semmelweiss’s 
book in 1861; although in 1864, Hirsch, after studying the matter from 
an historical standpoint, came to the conclusion that the malady w r as of 
infectious rather than of miasmatic origin. 

It was not, however, until after Lister had introduced antiseptic 
methods into surgery, and Stadfeld, of Copenhagen, had recommended 
the use of bichlorid of mercury in obstetrics, that the great mass of the 
profession began to understand that puerperal fever is due to contact 
infection, and can be prevented to a very great degree. The bacterio¬ 
logical work of Pasteur and his successors, and the almost constant pres¬ 
ence of streptococci in fatal cases, decided the question, and at present 
no one doubts the infectious nature of the disease. 

Modes of External Infection .—The most usual mode of infection is 
by the hands of the obstetrician or the midwife, and no one who has 
observed the way in which many medical men conduct labors can v r onder 
that puerperal fever occasionally occurs. The employment of dirty 
instruments, as well as dirty hands, also plays an important part. 

Sources of infection, much rarer, it is true, but generally overlooked, 
especially among the lower classes, are self-inoculation by the patient 
fingering her genitalia or even making internal examinations, and copu¬ 
lation during the latter days of pregnancy. Liepmann states that bac¬ 
teriological examination of the prepuce of the penis reveals the presence 
of streptococci in 75 per cent, of all cases; while I have seen several 






ETIOLOGY 


993 


patients die, and a number of others seriously infected, who had not 
been examined internally, hut who had copulated during the first stage 
of labor. Contact with wound secretion of any kind also plays an im¬ 
portant part, and whether the purulent material he from an external 
wound or elsewhere within the body, the result will he the same. 
Wounds on the hands of the physician or nurse, hone felons, and other 
affections of the fingers, such as a pustular eczema, are sometimes 
responsible. 

For many years it has been known that puerperal fever often occurred 
when a woman in labor was cared for by a physician who at the same 
time was attending a case of erysipelas. As has already been said, some 
of the old authorities held that the two affections were identical, but it 
was not until bacteriology had proved that erysipelas, as well as puer¬ 
peral infection, is due to the streptococcus that this relation was under¬ 
stood. At the present time it is generally believed that there is no 
essential difference between the streptococcus erysipelatis of Fehleisen 
and the ordinary streptococcus pyogenes. 

Puerperal fever has also frequently occurred in the practice of those 
attending diphtheria, scarlet fever, and occasionally typhoid patients. 
Although no essential relationship between these affections has been 
proven, it is w^ell known that in both diphtheria and scarlet fever com¬ 
plications due to the streptococcus are frequently met with, and these 
organisms may be conveyed to the woman in labor. 

Air infection was formerly supposed to play an important etiological 
part, and many authors advise covering the external genitalia with an 
occlusive pad to prevent the entry of air into the vagina, and thus elimi¬ 
nate the danger source of infection. It is doubtful, however, whether 
air infection is ever the cause of the disease. Nevertheless, in England, 
and to a less extent in this country, sewer gas is believed to play a promi¬ 
nent part in its production. But I believe that the danger of infection 
from this source will be spoken of less and less frequently as medical men 
become better versed in aseptic technic. 

To show how accurate a conception Semmelweiss possessed of the 
various modes of contact infection, it may be interesting to quote what 
he said concerning it: “The bearer of the decomposed animal-organic 
material is the examining finger, the operating hand, instruments, bed¬ 
clothes, atmospheric air, sponges, the hands of midwives or nurses which 
come in contact with the excrement of women sick with puerperal fever, 
and afterwards handle pregnant or parturient women. In other words, 
the bearer of the decomposed animal-organic material is anything which 
is soiled by a decomposed animal-organic material and comes in contact 

with the genitalia of these patients/’ 

Auto-infection .—At present it is universally accepted that the serious 
cases of puerperal infection are due almost without exception to the 
introduction from without of pyogenic bacteria into the genital canal of 
the pregnant or parturient woman. Nevertheless, many authoiities teach 
that occasionallv infection does not result in this mannei, but oves its 
origin to microorganisms which were already within the genital tract 
before the onset of labor. lo infection arising in this v ay the tenn 






994 


PUERPERAL INFECTION 


“auto-infection” is applied. The conception originated with Semmel- 
weiss, who stated: “In rare instances the decomposed animal-organic 
material, which causes childbed fever when absorbed, is produced within 
the patient herself. These are the cases of auto-infection, and cannot be 
prevented.” 

With the enthusiasm which attended the introduction of antiseptic 
methods into obstetrics, the possibility of auto-infection was lost sight 
of for a time, and it was only after the statistics of well-conducted 
lying-in establishments showed that a certain number of cases of infec¬ 
tion still occurred, despite the rigorous application of antiseptic prin¬ 
ciples, that the idea was rehabilitated by Ahlfeld and Kaltenbach (1883- 
1889). 

Of course, with the recognition of the fact that puerperal fever is due 
to bacterial infection, the definition introduced by Semmelweiss fell to 
the ground, since the microorganisms could not originate spontaneously 
within the body of the woman. Kaltenbach then advanced the view that 
pathogenic bacteria are normally present in the vaginae of a consider¬ 
able proportion of healthy pregnant women, and that these might make 
their way into the uterus, or be introduced into it by the sterile examin¬ 
ing finger. 

Apparent proof of the possibility of auto-infection is afforded by the 
rare instances in which serious puerperal infection develops in women 
who had not been examined vaginally, and whose labors had been con¬ 
ducted in a thoroughly aseptic manner. Such cases undoubtedly some¬ 
times occur, but even in them the proof is not convincing; as it is im¬ 
possible to prove that the infection might not be due to the patient 
handling her genitalia, or to bacteria which were brought to the uterus 
by means of the blood current. Reference to the latter mode of infec¬ 
tion has already been made in connection with the pneumococcus; and 
the streptococcus is sometimes similarly brought to the uterus in certain 
cases of angina, influenzal pneumonia, or other diseases. I was able to 
adduce convincing proof of its occurrence in influenza pneumonia, by 
demonstrating the presence of chains of streptococci in arterioles making 
their way through the uterine musculature to the decidua. 

Winter, in 1911, admitted the justice of these reservations, and held 
that one is justified in speaking of auto-infection only when bacterio¬ 
logical examination demonstrates that the bacteria found in the puer¬ 
peral uterus had existed in the vagina at the onset of labor. He con¬ 
siders that he has been able to adduce such proof, and therefore holds 
that auto-infection undoubtedly occurs. Accordingly, the solution of 
the question will depend upon the results of the bacteriological examina¬ 
tion of the generative tract during the last weeks of pregnancy. Un¬ 
fortunately, the investigations which have been undertaken for this 
purpose have not given uniform results, and consequently we are nearly 
as far from a scientific solution of the problem as when it was first 
broached; although in actual practice a constantly increasing number 
of obstetricians act on the supposition that auto-infection does not occur. 

All investigators are united in claiming that the cavity of the normal 
uterus is free from microorganisms both in the pregnant and non- 










ETIOLOGY 


995 


pregnant condition. This fact has been amply demonstrated by the 
work of Gonner, Doderlein, and Winternitz in women, and by Strauss, 
Sanchez-Toledo, and Denzler in the lower animals. 

Prior to 1898 it was generally believed that the cavity of the normal 
puerperal uterus was also free from bacteria, and that the demonstration 
of their presence afforded indubitable evidence of infection. In that 
year, however, Franz stated that bacteria could frequently be found 
after the first few days of the puerperium in women who had presented 
no clinical signs of infection. His publication was soon followed by 
others; and at first it was believed that the bacteria in question were 
merely saprophytes, but Stolz, Schenk, and Schieb found streptococci 
in from 30 to 38 per cent, of their cases. On the other hand, Foulerton 
and Bonney, Brownlee, and others stated that streptococci were never 
present. 

In view of these contradictory statements, my former assistant, H. M. 
Little, investigated the question. For this purpose he studied the uterine 
lochia obtained from 50 women delivered consecutively in my clinic in 
1904. In each case cultures were taken immediately after the expulsion 
of the placenta, and again on the third and ninth days of the puerperium. 
Not counting the gonococcus, the uterus was found to be sterile in 96, 
85, and 70 per cent, of the cases on the three days respectively, and 
in none of the 150 examinations were streptococci found. 

Little’s observations, indicate to my satisfaction that the normal puer¬ 
peral uterus at no time contains streptococci; but, on the other hand, it 
cannot be regarded as sterile except immediately after delivery, and 
becomes progressively more and more contaminated as the puerperium 
advances. The bacteria present are usually saprophytic in character, and 
while they may give rise to slight febrile disturbances they cannot be 
held responsible for the production of the grave forms of infection. 

In view of these investigations, it seems to me that the question 
of auto-infection must stand or fall with the demonstration of virulent 
streptococci in the vaginal secretion of healthy pregnant women. If 
they are even occasionally present, it must be admitted that they may 
be carried up into the uterus by the sterile examining finger, and give 
rise to infection; whereas if they are uniformly absent, such a con¬ 
tention must be dismissed as untenable. 

Unfortunately, the bacteriological investigations which have been 
undertaken to determine this question have served rather to complicate 
than to settle it; one set of observers claiming that streptococci are 
frequently present, and the other contending that, with the exception of 
the gonococcus, pyogenic bacteria are always lacking. 

The monograph of Doderlein on the vaginal secretion, published in 
1892, promised for a time to reconcile the conflicting results, but as 
his conclusions have not been confirmed by subsequent investigators, the 
question still remains an open one. He stated that the vaginal secretion 
might occur in one of two forms, which he designated as normal and 
pathological and which occurred in 55 and 45 per cent, of his patients, 
respectively The former was a thick, dry, cheeselike material of a 
whitish color and a distinctly acid reaction. Microscopically it showed 




996 


PUERPERAL INFECTION 


epithelial cells, a pure culture of tolerably long, thin bacilli, and occa¬ 
sionally a few yeast fungi. The pathological secretion, on the other 
hand, was fluid, generally of a yellowish color, suggesting pus, and some¬ 
times contained gas bubbles. Its reaction was less acid than that of 
the normal secretion, occasionally neutral, and very rarely alkaline. In 
it were found large numbers of leukocytes and many microorganisms of 
various kinds, both bacilli and cocci. As pyogenic bacteria were never 
present in the normal, while streptococci were noted in 10 per cent, 
of the pathological secretions, he held that auto-infection was out of the 
question when the secretion was of the first, but might occasionally 
occur when it was of the second type. 

Following Doederlein’s investigations an immense literature has ac¬ 
cumulated upon the subject, but unfortunately the results obtained have 
been extraordinarily contradictory. Thus, Kronig and I, in 1897 and 
1898 respectively, stated that streptococci could not be found in the 
vaginal secretion of normal pregnant women; whereas other investi¬ 
gators found them in a varying proportion of their cases—the extremes 
being represented by 4 per cent, in BurckhardPs series, and by 74 and 
100 per cent, in the series of Bumm and Sigwart, and Natwig, re¬ 
spectively. Naturally, such radical differences indicate that neither side 
has correctly faced all aspects of the problem, and that eventually a 
satisfactory solution must be attained. 

At one time, I thought that I had solved the problem, and that 
the contradictory results could be explained by differences in the technic 
employed for obtaining the secretion for examination, and that negative 
results were obtained when the secretion had been secured without con¬ 
tamination, while positive results were due to bacteria having been carried 
up from the vulva into the vagina when the sample of secretion was 
removed for examination. The correctness of this assumption was ap¬ 
parently substantiated by the examination of 25 pregnant women, from 
each of whom three sets of cultures were made. The first set was taken 
from the inner surface of the labia minora by means of an ordinary 
platinum loop; the second set was made from secretion obtained from 
the upper third of the vagina by means of a Menge tube, which effectivelv 
did away with the possibility of contamination from the external geni¬ 
talia, while in the third set, after introducing a speculum into the 
vagina, the secretion was taken from beyond its free end by means of 
a platinum loop. Pyogenic cocci or coion bacilli were present in 80 
per cent, of the first, but were entirely absent from the second set, 
thereby indicating that the vaginal secretion, when obtained by a technic 
which precludes the possibility of contamination, is free from pyogenic 
bacteria. On the other hand, such bacteria were present in 48 per 
cent, of the third set of cultures, which apparently showed that they 
had been carried up from the vulva by means of the speculum. 

This explanation apparently settled the matter for a few years, but 
in 1904 Bumm and Sigwart stated that my negative results were to be 
attributed to the employment of solid, instead of fluid, culture media, 
so that streptococci escaped detection. They stated that by the use of 
fluid media they had been able to demonstrate their presence in from 





ETIOLOGY 


997 


38 to 74 per cent, of a series of pregnant women, according as cultures 
were taken upon one or several occasions. It should be mentioned that 
they employed a speculum for obtaining the secretion, taking the speci¬ 
men from a portion of the vaginal wall, which presumably had not 
come in contact with it. 


Since then various other investigators have studied the problem, and, 
as a rule have reported that streptococci could be found in a varying pro¬ 
portion of cases, Jotten, for example, in 1912, having demonstrated 
them in 67 out of 100 women at the time of labor, and found that they 
were frequently of the hemolytic variety. He, however, attached no 
practical significance to their presence, as he stated that the puerperium 
was more frequently febrile in their absence. He furthermore made the 








interesting statement that he believed that the conflicting statements 
concerning their incidence were due to internal conditions in the various 
clinics rather than to errors in interpretation or in technic. 

As I felt that it should be possible to discover at least a clue toward 
the solution of this complicated question, I requested Dr. Willa Fricke 
in 1914 to take it up once more, but I am sorry to say that, while she 
apparently discovered an explanation for certain phases of the subject, 
her findings added still further to the confusion. She studied the vaginal 
secretion in 50 women awaiting delivery in the clinic, employing the 
same technic for obtaining it as in my original work, but utilizing a 
greater variety of culture media—particularly glucose bouillon. She 
found streptococci upon the vulva and in the vaginal secretion in 14 and 
8 per cent, of the cases respectively, and concluded that it made no dif¬ 
ference whether it was obtained by means of a Menge tube or a speculum. 
Her findings differed from mine in the occasional demonstration of 
streptococci, but more particularly by failing to demonstrate that bac¬ 
teria were carried up from the vulva into the vagina by the speculum. 

This 8 per cent, incidence of streptococci was so small in comparison 
to that recorded by many German investigators, that it seemed impor¬ 
tant to attempt to ascertain the cause of the discrepancy. It was, there¬ 
fore, tentatively suggested that the greater cleanliness of the patients 
in American hospitals might be a factor, and as a control, 47 out¬ 
patients were visited in their own homes without warning, and cultures 
were taken from the vulva, and from the vaginal secretion obtained by 
means of Menge’s tube. Streptococci were cultivated in 75 and 55 per 
cent, of the two sets of cultures, respectively, and approximately one 
third of them were of the hemolytic type. 

The difference between the two series is striking, and indicates that 
streptococci were demonstrated approximately seven times more frequently 
in the latter group, which is in close accord with the results obtained 
in the German clinics. As the only difference in the two series was in 
the personal cleanliness of the patients, Fricke regards it as an impor¬ 
tant factor in explaining the incidence of streptococci, but we should 
hesitate to suggest that it is the sole explanation for the different results 
obtained in the German clinics and in Baltimore. Fricke did not 
attempt to determine the virulence of the streptococci which she isolated, 
but the fact that none of the women in either series were seriously sick 





998 


PUERPERAL INFECTION 


after delivery, and the further fact that the 10 women, whose vaginal 
secretion contained hemolytic streptococci, had afebrile puerperia, in¬ 
dicates that the cocci concerned were clinically harmless. 

What practical conclusions can be drawn from the evidence which 
has just been adduced concerning the doctrine of auto-infection? In 
the first place it appears that the vaginal secretion of normal healthy 
pregnant women does not contain streptococci which grow upon ordi¬ 
nary agar. On the other hand, the preponderance of evidence indicates 
that in a varying proportion of patients it does contain streptococci, 
which grow readily in glucose bouillon. Furthermore, it is probable 
that the incidence of the latter depends in great part upon the personal 
cleanliness of the patient; and finally there is no evidence that the 
presence of such streptococci plays any part in the production of puer¬ 
peral infection. 

In other words it may be concluded that while bacteriological re¬ 
search affords a certain amount of evidence in favor of the theoretical 
possibility of auto-infection, clinical observation speaks against it. Ac¬ 
cordingly, the occurrence of serious streptococci infection should always 
be regarded as evidence of external infection. 

At the same time it is possible that auto-infection may occur from 
other organisms, which are present in the vaginal secretion, and plausi¬ 
bility is lent to such a supposition by the increasing frequency with which 
bacteria are found in the uterus with the advance of the puerperium; 
but satisfactory evidence cannot be adduced in support of such a con¬ 
tention until methods have been devised which will enable us to isolate 
and cultivate in pure culture the organisms in question, many of which 
are anaerobes which will not grow upon the usual media. 

The gonococcus forms an exception in this regard, as it is the only 
pyogenic coccus which can live and thrive in the vaginal secretion. As 
already indicated, it is a frequent cause of puerperal endometritis. Such 
cases, however, should not be considered as supporting the doctrine of 
auto-infection, for the reason that they represent contact infections, 
which had occurred before conception or in the first few months of 
pregnancy, after which the gonococci had led a parasitic existence in 
the crypts of the cervical canal, until thev found more suitable con- 
ditions for development during the first few days of the puerperium, 
when they made their way up into the uterine cavity and manifested 
their presence by the production of fever and an increased discharge. 

Likewise, one should not regard as auto-infection, in the strict sense 
of the word, those cases in which the bacteria are brought to the uterus 
from distant foci of disease by means of the blood current, nor those in 
which the process results from some preexisting affection of the genera¬ 
tive tract, such as an old pyosalpinx. 

An interesting fact in connection with the question of auto-infection 
is that those who believe most firmly in its possibility, and who employ 
the prophylactic vaginal douche for the destruction of the vaginal bac¬ 
teria, have been able to present less favorable statistics than their oppo- 
ments. The same may be said concerning the more recent proposals to 
employ a one-half per cent, solution of lactic acid as a prophylactic 




ETIOLOGY 


999 


measure, with the idea than an increase in the acid titre of the vaginal 
secretion will lead to the destruction of pyogenic bacteria and favor 
the growth of the characteristic vaginal bacillus. This question was 
considered in detail by Hamm in 1918. 

Frequency.—It is difficult to make accurate statements as to the fre¬ 
quency of puerperal infection, especially when it occurs outside of 
hospital practice. Concerning this condition the vital statistics of the 
health offices of the various American cities are of little value, inasmuch 
as many of the deaths from this disease are returned as being due to 
malaria, typhoid fever, pneumonia, or other causes. Dublin, in 1918, 
estimated that it was responsible for 43 per cent, of all deaths incidental 
to child-birth in this country; while Howard calculated, in 1921, that 
one out of every 406 women who become pregnant die from infection, 
and stated that “these rates are probably unparalleled in modern times 
in a civilized country.” 

Since the introduction of antiseptic methods into midwifery the mor¬ 
tality'from puerperal infection has decreased very markedly in hospital 
practice. Formerly, in the old Maternity of Paris, and in the Lying-in 
Hospital in Vienna, it varied from 10 to 15 per cent., so that finally it 
attracted the attention of the public, and steps were being taken to 
abolish such institutions as a menace to public health. With the intro¬ 
duction of aseptic methods, however, all this was changed, so that at 
present in well-regulated lying-in hospitals the mortality from infection 
is usually only a small fraction of 1 per cent., Pinard, in 1909, having 
reported a mortality of 0.15 per cent, in 45,633 deliveries. Hence it 
happens that at the present time, in the discussions upon the subject, 
so far as hospitals are concerned, the question is rather one of mor¬ 
bidity than of mortality, and deals with the percentage of patients whose 
temperature rises above 38° C. or 100.4° F. during the puerperium. 

On the other hand, in private practice it is doubtful whether the 
results are materially better to-day than they were before the introduc¬ 
tion of antiseptic methods, for the reason that the doctrines of asepsis 
have not yet permeated the rank and file of medical men, much less of 
midwives, to whose care is committed a large proportion of obstet¬ 
rical cases. Though, at the same time, it must be admitted that we 
rarely hear of outbreaks of puerperal infection such as were mentioned 
in the historical work of Hirsch, who gave the particulars of 216 epi¬ 
demics occurring between the years 1652 and 1862. 

Boehr stated in 1875 that 363,324 women had died from puerperal 
infection in Prussia during the preceding 60 years, and calculated that 
every thirtieth married woman eventually perished from it; while Ehlers 
contended that outside of the well-regulated hospitals the results were 
equally bad in 1900. Furthermore, Fromme stated, in 1910, that at 
least 5,000 women succumb each year in Prussia to this preventable 
malady. 

Meigs stated that in the registration area, which includes somewhat 
less than two-thirds of our population, 4,542 deaths from puerperal in¬ 
fection were recorded during the year 1913. She makes a still more 
startling arraignment by comparing the deaths from typhoid fever, diph- 




1000 


PUERPERAL INFECTION 




theria, tuberculosis and puerperal infection in the years 1900 and 1913 
respectively. During this period the three first-mentioned diseases show 
a decrease of over one-half, as contrasted with a slight increase for 
puerperal infection. 

Howard, and Eichel in 1921 and 1922, respectively made impor¬ 
tant statistical studies and reached practically identical conclusions. 
The former studied the census figures for 1918 for the birth registration 
area, which includes 53 per cent, of the population, and found that one 
out of every 113 women delivered during that year died from some 
cause connected with childbirth—27.8 per cent, from infection. Howard 
stated that these results were 120 per cent, higher than in England and 
Wales, and then made the startling statement that, upon dividing the 
material into urban and rural, according as the women lived in localities 
having ten thousand inhabitants or less, the results w r ere w^orse in the 
former group, the incidence of infection being one-fifth higher in the 
urban than in the rural population. 

Eichel studied the conditions obtaining in the State of Hew York 
for the five years ending with 1920. During this period he found that 
approximately one and a quarter million births had occurred, 'which 
were almost equally divided between the City and State of Hew York. 
In the former, one woman died in every 214 labors, while in the latter, 
the proportion increased to 1 to 151. He attributed the relatively good 
results in Hew York City to its w^ell-conducted hospital facilities and 
to the presence of trained specialists. Upon analyzing more closely the 
figures for the State outside of the City of Hew York, he reached con¬ 
clusions similar to those of Howard, and found that labor was consider¬ 
ably safer in rural communities than in the cities and villages with 
more than 2,500 inhabitants. In other words, Eichel found that it w'as 
one-half again as dangerous to have a baby in the latter localities as in 
the City of Hew York, and one-fifth more dangerous than in the open 
country, where physicians were not always available. 

Furthermore, he stated that while the figures for the entire State 
for the years 1911 to 1916 showed a gradual decrease in the puerperal 
death rate from all causes, a progressive rise having occurred from 1916 
to 1921, so that the risk-rate had become one-eighth greater in the 
latter year. This tendency, however, is not peculiar to America, as Eden 
has noticed it in England, and German writers refer to its occurrence 
in their country, but without giving actual figures in support of their con¬ 
tention. In general, it may be attributed to the disorganization of 
medical practice incident to the World War. 

Such figures seem to indicate that while preventive medicine has 
played a stupendous part in diminishing the incidence and mortality 
of the infectious diseases, that of puerperal infection has not been 
affected, except in the largest centers where w r ell-conducted lying-in 
hospitals and trained specialists are available. The figures of Howard 
and Eichel, which set forth the appalling conditions obtaining in the 
smaller cities and towns of the country, constitute a striking arraign- 
ment of our system of obstetrical training, and indicate that the rank 
and file of medical practitioners are no better trained than their predeces- 












ETIOLOGY 


1001 




sors, and consequently with the single exception of tuberculosis, puerperal 
infec ion still constitutes the most important cause of death among 
women during the child-bearing period. 

,.,. The “veshgations of Boxall, Byers and Lea show a similar con- 
dition m Great Britain, where it may be said that outside of the lying-in 
hospitals this preventable scourge claims as many victims as forty years 
ago. Eden in 1922 pointed out that the mortality from childbirth had 
actually increased from 1911 to 1920, and that while the proportion of 
deaths fiom the complications of pregnancy and the accidents of labor 
had decreased, that from infection was actually greater. 

Moreover, in attempting to ascertain the frequency of puerperal infec¬ 
tion, one cannot be guided altogether by the mortality statistics, inas¬ 
much as the greater proportion of such cases do not end fatally. On 
the other hand, no one who has to deal with gynecological patients 
can fail to be impressed with the very large proportion whose troubles 
have originated from febrile affections during the puerperium, which 
in most instances were due to the neglect of aseptic precautions on the 
part of the obstetrician or midwife. 

Symptoms —As was stated when considering the pathological anatomy 
of puerperal infection, the common lesion is an endometritis. This may 
be either of the septic, putrid or gonorrheal variety, each type present¬ 
ing a group of more or less characteristic symptoms. 

In the case of septic endometritis, after everything has gone smoothly 
for the first three or four days of the puerperium, the patient suddenly 
experiences some malaise, and complains of headache and a feeling of 
chilliness, or she may have a well-defined chill, the temperature rising to 
103° F. or higher. Generally, only one rigor occurs, after which the 
temperature remains constantly elevated. At the same time there is some 
tenderness in the lower part of the abdomen, the uterus is larger and 
more doughy in consistency than it should be, and is sensitive on pres- 
The lochial discharge is sometimes increased in quantity, and is 


sure. 


partly bloody, partly purulent in character, and may be practically 
devoid of odor. If the temperature is very high the secretion may be 
diminished in amount, and occasionally disappears almost entirely. 

The character of the uterine discharges in these cases often leads 


to a mistake in diagnosis, for the average practitioner associates puer¬ 
peral infection with profuse and foul-smelling lochia; whereas, in reality 
in the more virulent streptococcus cases, there is very little, if any, 
odor, and its absence, therefore, is not necessarily a favorable indication, 
but rather the reverse. 

Another point of importance is the faulty involution of the uterus. 
This must be looked upon as an important factor in the further spread 
of the disease, for the microorganisms make their way through the mus¬ 
cular walls of the uterus by means of the lymphatics, and when the 
orjran is markedlv relaxed these channels are more patent and offer 
less resistance to the outward passage of the bacteria than when firm, 
normal contraction is present. 

The further history of septic endometritis'varies according as the 
process remains limited to the cavity of the uterus or extends beyond it. 






1002 


PUERPERAL INFECTION 


In the former case the temperature gradually falls, the secretion become ] 
less and less, and the patient is slowly restored to health. The mucosa J 
however, is not restored to its normal condition at once, but for som< I 
time remains the seat of a subacute or chronic inflammation. Whei 
the process has extended beyond the uterus the symptoms will van 1 
according to the organs involved, and those belonging to a parametritis 1 
peritonitis, or pyemia, as the case may be, are superadded. 

In putrid endometritis we may likewise have the initial chill and the 
high temperature, but the patient’s condition does not usually appear sc j 
serious as in the septic form. The main difference, however, is to be 
noted in the character of the uterine discharge, which, in the putrid j 
cases, is abundant, very foul-smelling, and frequently has a frothy ap¬ 
pearance. These cases usually eventuate in recovery. Between these ; 
two well-marked types of cases, however, there exist all gradations, and j 
not uncommonly we have to deal with a mixed infection due to pyogenic 
as well as putrefactive organisms. 

In gonorrheal puerperal endometritis the symptoms are usually very 
characteristic. The first days of the puerperium are normal, and about 
the end of the first week, just as one is congratulating one’s self that : 
all is well, the temperature suddenly rises, usually without a chill, and 
remains elevated for a week or ten days, gradually falling to normal | 
without treatment. Usually there is some abdominal tenderness and 
pain, which may become pronounced if the process extends beyond the | 
tubes, which happens in only a small proportion of cases. In not a few 
cases, the diagnosis is facilitated by the development of ophthalmia 
neonatorum several days before symptoms appear in the mother. Ordi- [ 
narily only palliative treatment is required, and a few days additional 
rest in bed. Actual cure, however, can scarcely be expected, as the 
process tends to become chronic, and may lead to permanent sterility 
or to the development of chronic pelvic inflammatory disease, which may 
require operative interference months or years later. 

The extension of the infection from the uterine cavity, or from cervi¬ 
cal tears, to the parametrium produces an array of more or less character¬ 
istic manifestations. In many cases the initial rise of temperature lasts 
only for a few days, and we are congratulating ourselves that the patient 
has escaped so easily when suddenly another chill occurs, the tempera¬ 
ture rises again, to pursue a more or less irregular course, usually 
marked by evening exacerbations. Within a few days vaginal examina¬ 
tion or abdominal palpation will reveal the presence of a mass on one 
or both sides of the uterus, due to pus formation within the folds of 
the broad ligament. The abscess may be limited to this location, or, as 
it becomes larger, it may dissect off the peritoneum from the anterior 
portion oi the pelvis and the abdominal wall, and form a tumor whose 
upper margin extends well above Poupart’s ligament; in other cases, 
again, it extends backward toward the retroperitoneal region. The fever 
continues until the abscess has been opened or ruptures spontaneously, 
except in the few instances in which it undergoes gradual resorption, 
leaving a mass of cicatricial tissue to mark its former situation. If not 
operated upon, a parametritic abscess may burst spontaneously into the 











ETIOLOGY 


1003 


rectum or bladder, and occasionally through the abdominal wall in the 
region of the inguinal canal. Uidess it ruptures into the peritoneal 
cavity the patient usually recovers with proper care. 

In rare instances the infection extends from the uterine cavity to 
the fallopian tubes, and gives rise to a salpingitis with its accompanying 
symptoms. A considerable proportion of the cases of pyosalpinx fol¬ 
lowing abortions, which come to operation months or years later, have 
originated in this manner. 

Unfortunately, it frequently happens that the infectious process does 
not remain limited to the uterus or to the parametrium, but the micro¬ 
organisms make their way through the lymphatics of the muscular wall 
of the uterus to the peritoneum, and there excite a peritonitis; though 
in exceptional instances the latter may result from an extension of the 
inflammation from the tubes, and occasionally from the rupture of a 
parametritic, ovarian, or tubal abscess. 

Particularly in gonorrheal infections, the peritoneal implication is 
limited to the portion lining the pelvic cavity—pelvic peritonitis—but 
in streptococci infections it tends to become generalized. In the former 
event, recovery is the rule, whereas in the latter death is almost inevi¬ 
table. The characteristic symptoms of peritonitis usually make their 
appearance during the first week of the puerperium, but rarely before 
the third or fourth day. If they occur at a later period the process is 
usually due to the rupture of an abscess. 

When very virulent streptococci are the infecting agents the endo- 
metritic implication is usually very slight, and practically the first sign 
of infection appears from the side of the peritoneum. A definite rigor 
occurs, the temperature rises rapidly and remains constantly elevated, the 
pulse becomes rapid, and later on very weak and thready in character. 
The patient may complain of intense pain, which is .ai first limited 
to the lower portion but gradually extends over the entire abdomen. At 
the same time there is marked tympanites, and the abdominal walls 
are rendered tense by the distended intestines. If a fatal issue ensues 
death usually occurs within ten days after delivery, the patient gradually 
sinking, although she may remain conscious to the last. In other cases, 
however, the clinical symptoms do not correspond to the gravity of the 
lesion; the temperature is but little elevated, the pain slight, and the 
abdominal symptoms slightly marked, or even absent, the serious char¬ 
acter of the condition being indicated only by the rapid and compressible 
pulse and the drawn and haggard facies. 

In the cases of pyemia, on the other hand, the clinical picture is 
very characteristic. Here the initial chill rarely occurs before the end 
of the first week, and the temperature does not remain constantly ele¬ 
vated, but instead we have a typical hectic fever, with the chill, high 

[ temperature, and remission recurring in succession. The symptoms 
vary very considerably, according as one has to deal with the dislodgment 
of a single thrombus or of the repeated entry into the blood of small 
infected particles. In the first instance a metastatic abscess develops 
at some one point, the symptoms depending upon the organ involved. 



1004 


PUERPERAL INFECTION 


On the other hand, if thrombi are being constantly dislodged we may 
have symptoms referable to various organs. 

One of the most constant manifestations of pyemia is an infectious 
bronchopneumonia, which contributes to the fatal termination. In other 
cases swellings occur at the various joints, which frequently eventuate in 
suppuration and lead to total destruction of the tissues implicated. Ab¬ 
scesses may also develop in the internal organs or appear upon the 
surface, and in several instances I have seen them lead to the destruction 
of the eye. The course of pyemia varies according to the organs attacked 
and the resisting powers of the patient, and weeks, or sometimes months, 
elapse before death occurs or recovery ensues. In general, it is less fatal 
than the peritonitic form of infection, but unless prompt resource is 
had to surgical intervention, its mortality is in the neighborhood of 
60 per cent. 

In rare instances the infection is so virulent that the bacteria do 
not have a chance to become localized in any one organ, and both 
they and their toxins are found in abundance in the circulating blood, 
with very slight implication of the uterus. This results in the so-called 
acute septicemia —the sepsis foudroyante of the French writers—which 
represents the most rapidly fatal form of infection, the patients occa¬ 
sionally dying on the second or third day after delivery in a condition 
of shock, and without the development of local symptoms. A case of 
streptococcus septicemia, observed in our out-patient department, ended 
fatally within eighteen hours after the initial rise of temperature. 

Occasionally, the thrombotic process involving the pelvic veins may 
extend to the femoral, and sometimes to the saphenous, vein on one or 
both sides, giving rise to phlegmasia alba dolens. This accident, as 
a rule, does not make its appearance until some time in the second 
or third week of the puerperium, or even later, the first symptom being 
pain along the course of the involved vessels, which, in thin individuals, 
may be felt as hard, sensitive cords. At the same time edema appears 
in the feet and soon extends upward, though occasionally it may appear 
first in the thigh. This swelling is associated with severe pain, and 
usually lasts for a considerable time, months sometimes elapsing before 
the patient can walk with comfort. The condition is rarely fatal unless 
some complication occurs. At the onset of phlegmasia many patients 
complain of severe pain about the chest. This symptom is attributed 
by Plnard and YTallich to the arrest of minute emboli in the smaller 
vessels of the lung, with subsequent infarction and the development of 
isolated areas of pleurisy. 

In a certain number of cases infection may occur before the birth of 
the child. This is designated as intrapartum infection , and usually oc¬ 
curs in slow labors in which the membranes have ruptured prematurely. 
In such circumstances the temperature may be markedly elevated and 
the patient present a profoundly septic appearance even before delivery. 
A\hen the temperature during labor rises above 100.5° F., we should 
always think of this complication, and at once institute procedures to 
hasten the evacuation of the uterus. 



DIAGNOSIS 


1005 


Diagnosis.—The diagnosis of puerperal infection is usually made 
without difficulty, as the clinical history is very significant. 

If a patient, who has been doing well after delivery, has a rise of 
temperature on the third or fourth day exceeding 100.4° F. (38° C.), 
which persists for more than twenty-four hours, we may be practically 
sure that we have to deal with an infection, unless some other perfectly 
apparent condition will account for the symptoms. The occurrence of 
an initial chill adds to the probability of the diagnosis. In the old 
times it was believed that the onset of the lacteal secretion was accom¬ 
panied by fever, and the older observers were always ready to attribute 
a rise of temperature on the third or fourth day to this cause. At 
present, however, this so-called “milk fever" is no longer regarded as 
a morbid entity, as we know that the normal puerperium should be 
afebrile. 

In uncomplicated cases of puerperal endometritis usually very little 
pain is__complained of, and it sometimes becomes a difficult matter to 
decide positively whether the temperature is due to a uterine infection 
or some other cause. After the infection has become well established, 
either as an endometritis, peritonitis, or one of the other forms, the 
diagnosis is generally easy, and it is hardly possible to mistake the 
symptoms produced by a peritonitis or by a pyemia. In the cases of 
parametritis and suppurative affections of the tubes and ovaries, biman¬ 
ual examination will demonstrate the presence of a mass on one or other 
side of the uterus, if the tumor has not already made itself evident to 
abdominal palpation. 

Occasionally a febrile movement may occur between the seventh and 
fourteenth days, which may possibly be ascribed to emotional causes , 
such as excitement, fright, or grief. In this event the temperature may 
rise suddenly, and after reaching a considerable height promptly fall to 
normal within a few hours. Such a diagnosis is not permissible if the 
temperature remains elevated for twenty-four hours. Now and again 
a somewhat similar rise is caused by auto-intoxication from the intestinal 
tract. The diagnosis, however, is readily arrived at by the administra¬ 
tion of a purgative, for after a copious movement of the bowels the 
temperature falls rapidly and remains normal. Again, fever occurring 
in the early part of the puerperium is sometimes due to inflammatory 
troubles about the breasts, but the subsequent history of the case readily 
clears up the question of diagnosis. 

In addition to the conditions just mentioned, many intercurrent dis¬ 
eases may be accompanied by chill and high temperature, temporarily 
making one suspect puerperal infection, although the subsequent history 
shows that one’s fears have been groundless. This is frequently so in 
angina, acute pulmonary affections and pyelitis. Occasionally prolonged 
suppurative processes in other parts of the body may be accompanied by 
symptoms which may be confounded with puerperal infection, but in 
the present state of our knowledge there is no reason why we should long 
remain in doubt as to the cause and origin of the fever in a gh en case. 

In the past malaria and typhoid fever were frequently confounded 
with puerperal infection, and were often made the scapegoat to shield 





1006 


PUERPERAL INFECTION 


the practitioner who had neglected aseptic precautions in the conduct 
of his case. While there is no doubt that either affection may occur 
during the puerperal period, in the vast majority of cases the diagnosis 
is open to question. If the symptoms be due to malaria one should be 
able to demonstrate the presence of the specific parasites in the blood; 
but in default of a positive finding one is not justified in making such 
a diagnosis. 

The diagnosis of typhoid fever is frequently made in prolonged cases 
of puerperal infection, being based on the long-continued fever and the 
general prostration of the patient. No doubt such a complication occa¬ 
sionally occurs, but in the present state of our knowledge we are not 
justified in making such a diagnosis unless a positive Widal reaction can 
be demonstrated. On the other hand, typhoid fever complicating the 
puerperium may simulate very closely a puerperal infection. Jung has 
described several cases in which the true nature of the malady was not 
discovered until autopsy, and I have had a similar experience. Likewise, 
an acute miliary tuberculosis, or the flaring up of a chronic process during 
the puerperium, may occasionally simulate an infection, or may mask 
its symptoms. 

To sum up, it may be said that it is a safe rule to regard every rise 
of temperature occurring in a puerperal woman as due to infection until 
it has been clearly demonstrated that some other exciting cause is respon¬ 
sible. Hence it follows that, in making a diagnosis of any febrile affec¬ 
tion complicating the puerperium, an accurate and complete physical 
examination of the patient is necessary, in which all the aids which the 
reeent advances in diagnostic methods have placed at our command 
should be utilized. 

Bacteriological Examination of the Lochia .—As the most common 
lesion in puerperal infection is an endometritis, it is a matter of great 
importance to decide whether one has to deal with the septic, putrid or 
gonorrheal variety; but, although in many cases the clinical symptoms 
will give tolerably definite indications, a positive conclusion can be ar¬ 
rived at only after a bacteriological examination of the uterine lochia. 
In gonorrheal infections the development of a purulent ophthalmia on 
the part of the child justifies a positive diagnosis, but even in such cases 
one is not sure that other organisms may not be concerned. 

Cultures may be taken from the interior of the uterus with compara¬ 
tively little difficulty by means of a simple device first introduced by 
Doderlein and modified by H. M. Little. This consists of a glass tube 
20 to 25 centimeters in length and 3 to 4 millimeters in internal diame¬ 
ter, with a slight bend at one end so as to conform to the anteflexed 
condition of the uterus. It is threaded with a piece of strong silk, to 
one end of which a folded rubber band is attached, which exerts suction 

when traction is made upon the free extremity protruding from the other 
end of the tube. 

When cultures are to be made the necessary instruments and lochial 
tube are sterilized by boiling, and the hands of the operator and the 
external genitalia having been thoroughly disinfected, the patient is 
p aced in the Sims' or dorsal position and the cervix exposed by a suit- 


DIAGNOSIS 


1007 


able speculum. It is then seized with a volsellum forceps and, its vaginal 
portion having been carefully cleansed with a bit of sterilized cotton, the 
lochial tube is introduced as far as possible into the uterus, care being 
taken to avoid touching the external genitalia with it during the manipu¬ 
lation. On making traction upon the thread protruding from the free 
end of the tube, a partial vacuum is created and a certain amount of 
lochia is drawn up. The tube is then removed from the uterus and its 
ends hermetically closed with sealing wax. After being taken to the 
laboratory it is broken in its middle portion and cultures are made from 
the contents (Fig. 690). This method can be readily carried out by 
any practitioner, who is conversant with the ordinary rules of surgical 
technic, and if the tube be sent to a competent bacteriologist, it can be 
determined within twenty-four hours to what type of bacteria the in¬ 
fection is due. 

In my practice this procedure forms a part of the routine examina- 



Fig. 690. —Little’s Tube for Obtaining Uterine Lochia. 


tion in every puerperal patient presenting a rise of temperature above 
101° F., and lasting for more than twenty-four hours. It gives most 
reliable information if employed during the week following delivery, but 
after that period the results are not so decisive; as the uterine lochia in 
the latter part of the puerperium practically always contain putrefactive 
bacteria. I consider that this technic is preferable to the examination 
of the vaginal lochia obtained by means of cotton swabs, as recommended 
by many German authorities. The former method gives precise infor¬ 
mation concerning the bacterial contents of the uterus, while the latter 
necessitates the inference that the uterine and vaginal flora are identical, 
which is by no means always the case. 

As has already been indicated, it was for a time believed that the 
demonstration of the presence of hemolytic streptococci always indicated 
the existence of a virulent infection. This, however, is incorrect, as it 
has been demonstrated that such bacteria may give rise to benign infec¬ 
tions, or may even be present in healthy women. In general, it must be 
admitted that they are more frequently associated with serious infections 
than the non-hemolytic variety. 

Hirst believes that the examination of the uterine lochia may lead to 
erroneous conclusions, as it may give negative results, while at the same 
time bacteria can be cultivated from the blood. In my experience, how¬ 
ever, this is not the case in early infections, but after the first ten days 
of the puerperium, and especially in certain prolonged cases of pyemia, 

















1008 


PUERPERAL INFECTION 


his contention is probably correct. On the other hand, if reliance were 
placed solely upon blood cultures, as he advised, practically all of the 
mild and some of the severe cases of infection would escape differentia¬ 
tion. In the former, bacteria rarely gain access to the circulation, while 
in the latter the reverse usually holds good; although I have seen several 
women die from infection in whom repeated examinations of the blood 
gave negative results both during life and at autopsy. 

In my opinion, therefore, the bacteriological examination of the 
blood is of secondary importance from a diagnostic point of view, 
although it should always be made in seriously sick patients, as the dem¬ 
onstration of streptococci adds to the gravity of the prognosis. It does 
not, however, necessarily indicate a fatal termination, as I have repeat¬ 
edly seen recovery occur in patients whose blood contained hemolytic 
streptococci, and in some instances they were but slightly sick. 

The macroscopic appearance of the lochia is also of considerable 
value, for in putrid endometritis the discharge is frothy and frequently 
very offensive in odor, while in pure streptococcic infections it is very 
little changed from the normal. This distinction needs to be especially 
emphasized, since the first question which the practitioner usually asks 
in the presence of fever during the puerperium is whether the lochia are 
foul-smelling, and if he receives a negative answer he is too apt to 
think that the fever is of other than uterine origin. As a matter of fact, 
the reverse is almost constantly true, and, as a rule, the foulness of the 
odor is in inverse proportion to the danger to which the patient is 
exposed. 

Prophylactic Treatment.—In considering the treatment of puerperal 
fever, prophylaxis should occupy the most important place. As has been 
repeatedly insisted, it is a wound-infection, due to the introduction of 
pyogenic microorganisms by the hands or instruments of the doctor or 
nurse. Hence, it follows that the most scrupulous asepsis immediately 
before and during labor is the means upon which we have mainly to rely 
to limit its occurrence. Every physician who conducts a labor case 
cannot feel too strongly his personal responsibility in this connection, 
and he fails to do his full duty to his patient unless he regards the rules 
of asepsis as carefully as when performing a capital surgical opera¬ 
tion. 

As long as vaginal examinations are made, infection will occasionally 
occur, even though the carefully disinfected hand be covered by a sterile 
rubber glove. As it is impossible to disinfect the vulva thoroughly, it 
must inevitably happen that bacteria are carried up into the vagina from 
it with each examination, and it is therefore not surprising that infec¬ 
tion sometimes occurs. For this reason vaginal exploration should be 
dispensed with as far as possible, and with this end in view the obstet¬ 
rician should perfect himself in the methods of rectal and external 
examination. 

All that has been said concerning the necessity of cleanliness and 
asepsis on the part of the physician applies equally well to the nurse, 
and in all her manipulations about the patient she should never forget 
her responsibility in this respect. Moreover, she should be strictly for- 


CURATIVE TREATMENT 


1009 


bidden to make vaginal examinations or give douches except at the direct 
request of the physician in charge. 

In view of what has already been said concerning practical sterility 
of the normal vaginal secretion, I strongly advise against the employment 
of the 'prophylactic douche as a routine procedure, believing that except 
when the vaginal secretion presents marked evidences of abnormality it 
does more harm than good. 

During the second stage of labor the vulva should be covered with 
an aseptic pad in the form of a towel soaked in bichlorid solution. This 
is done not so much for fear of air infection, as to prevent the possibility 
of contamination from the patient’s hands. The third stage of laboi 
likewise offers many facilities for infection, and too much stress cannot 
be laid upon its proper conduct. Speaking broadly, the generative tract 
after the birth of the child should be regarded as a noli me tang ere, 
unless an emergency, such as hemorrhage or an adherent placenta, 
necessitates the introduction of the hand. The recommendation that a 
routine vaginal examination is called for in order to detect cervical tears 
with a view to their immediate repair, cannot be too strongly depre¬ 
cated, and those who follow it will encounter a larger puerperal morbidity 
than when such examinations are reserved for exceptional and urgent 
cases. 

Another point in the prophylaxis of puerperal infection is to close 
with sutures immediately after the conclusion of labor all perineal 
wounds, unless the procedure is contra-indicated by profound exhaustion 
on the part of the patient, or by a very edematous condition of the tis¬ 
sues implicated. To save time, it is my practice to introduce the sutures 
immediately after the birth of the child, and while waiting for the expul¬ 
sion of the placenta. 

To recapitulate, the liability to puerperal infection will be materially 
lessened by the strict observance of the following: (1) The maintenance 
of strict asepsis by the obstetrician and nurse before, during, and after 
delivery; (2) the restriction of vaginal examinations within the narrow¬ 
est limits possible; (3) the greatest possible utilization of abdominal pal¬ 
pation and rectal examination; (4) the omission of prophylactic vaginal 
douches; (5) the immediate repair of perineal lacerations which might 
otherwise offer foci for infection; and (6) regarding the genital canal 
of the puerperal woman as a noli me tangere, into which neither finger 
nor instrument should be introduced except in emergencies. 

Curative Treatment.—The curative treatment of puerperal infection 
is a question concerning which there is much dispute, and it is probable 
that what is said here may be directly opposed to the usual practice of 
many physicians. 

If a puerperal ulcer is situated about the vulva or on the lower por¬ 
tion of the vagina, it should be occasionally touched with pure carbolic 
acid or tincture of iodin, and the parts kept as clean as possible. If the 
repaired perineum breaks down and suppuratesTthr stitches should be 
removed in order that free drainage may be provided. 

As puerperal endometritis is the form of infection most frequently 


1010 


PUERPERAL INFECTION 


encountered, its treatment is most important; unfortunately the direc¬ 
tions for it differ widely and are often contradictory. 

Whenever the temperature remains at 101° F. for more than 24 
hours, unless a uterine infection can be excluded with a fair amount of 
certainty, the uterine lochia should be examined bacteriologically. Imme¬ 
diately afterwards an abundant saline douche should be given. 

Curettage as a routine measure in all cases of puerperal endometritis 
cannot be condemned too strongly, for the reason that in the most viru¬ 
lent infections there usually is nothing in the uterine cavity which 
can be removed, and its employment can only do harm by breaking down 
the leukocytic wall which serves to prevent the invasion of the deeper 
layers of the uterus by the offending bacteria. On the other hand, when 
the uterus contains a quantity of debris, its removal is quite as readily, 
and much more safely, effected by means of the finger. This teaching 
is directly contrary to that formerly given by many writers, who have 
enthusiastically recommended the use of the curette in puerperal infec¬ 
tion, although now, I am glad to say, much greater conservatism is 
practiced, and the dangers of the procedure are generally recognized. 

The routine use of intra-uterine douches containing bichlorid or other 
disinfectants in the treatment of these cases is contra-indicated on 
several grounds. In virulent streptococcus infection, histological 
examination shows that the organisms have penetrated deep down into 
the tissues by the time the initial chill and rise of temperature occur. 
In these circumstances the germicidal fluid cannot penetrate the uterine 
wall sufficiently deeply to reach the bacteria, upon which the further 
spread of the disease is dependent. 

How little penetration occurs was shown experimentally by Bumm. 
He soaked the liver of an animal dead of anthrax in a 1 to 1,000 
bichlorid solution for thirty minutes, and then cut sections from it with 
a freezing microtome. After cutting off about 1/10 of a millimeter, 
he inoculated the next section into a laboratory animal, which suc¬ 
cumbed to anthrax, thus showing that the germicidal action had been 
exerted only upon the surface. If this be the case in the laboratory, 
where the tissues can be immersed in the antiseptic solution for any 
desired length of time, what effect can the transitory application of a 
few liters of weak bichlorid solution have upon bacteria, which are im¬ 
bedded in the depths of the decidua or even in the muscular wall of the 
uterus ? Bumm likewise insisted that satisfactory results could be hoped 
for only when the douche was given simultaneously with the first appear¬ 
ance of symptoms, as he showed that streptococci could make their way 
through the uterus with great rapidity, being able to travel 2 centimeters 
or more in the space of six hours. 

On the other hand, the employment of antiseptic douches in putrid 
endometritis is even less rational, as in such cases simply cleaning out 
the uterus by a douche of sterile salt solution, will lead to a rapid fall 
of temperature and the amelioration of untoward symptoms. As the 
object of the douche is merely to wash away the debris > sterile salt solu¬ 
tion is superior to any antiseptic fluid for the purpose. 

In addition to these somewhat theoretical objections, there is this 


CURATIVE TREATMENT 


1011 


very practical one: namely, that the employment of antiseptics may in 
many cases do actual harm. Not a few cases of sudden collapse follow¬ 
ing the use of carbolic-acid douches are on record, while in some in¬ 
stances intra-uterine injections of bichlorid have been the direct cause 
of death. For example, at the autopsy upon a woman who was supposed 
to have died from puerperal sepsis, I found all the anatomical lesions of 
bichlorid poisoning, so that, to say the least, it remained doubtful 
whether the infection or the treatment instituted for its relief was 
responsible for the fatal issue. 

On reference to the literature, I collected a large number of cases 
in which death had followed the employment of intra-uterine bichlorid 
douches during the puerperium. In many instances, to be sure, exces¬ 
sive quantities had been employed, but in several a single injection of 
several liters of a 1 to 4,000 solution had resulted in fatal mercurial poi¬ 
soning. Consequently, when these facts are taken into consideration, 
it would appear that the benefit to be expected from their employment 
is at least very problematical, while the dangers are very real. 

The same considerations likewise apply to the various other anti¬ 
septic agents which have been recommended from time to time. Nor 
am I inclined to place great confidence in the disinfectant properties of 
injections of alcohol, as recommended by Wetherill, Sitsinsky, and 
others. At the same time it must be admitted that the uniform success 
obtained by the latter in 246 cases of infection speaks in its favor. The 
results thus far reported from the use of irrigations with Dakin’s solu¬ 
tion in the treatment of puerperal endometritis are not encouraging, 
and tend to indicate that the conditions are not identical with those 
obtaining in infected wounds in other parts of the body, in which such 
signal success has been obtained. So far as I am aware, Piper’s publi¬ 
cation is the only one dealing with the use of mecurochrome, and his 
results were not encouraging. At the same time, it should be said that 
the number of cases treated was too small to justify any conclusion as 
to its value, and it is to be hoped that wider experience may indicate 
that it will serve as useful a purpose in the treatment of puerperal 
infection as it has in other affections. 

The results following the somewhat nihilistic method of treatment 
just outlined are, to say the least, quite as good as those obtained by 
more radical measures, and this contention is sustained by the experi¬ 
ence of Bumm and Kronig. By this means I have had a mortality of 
considerably less than 10 per cent, in my cases of streptococcic infec¬ 
tion, which would be still further reduced were we to exclude the patients 
who were suffering from general peritonitis or severe pyemia at the time 
of admission. On page 983, attention was called to the fact that no 
fatalities occured in the 61 cases treated during the year ending July 
14, 1923. At the same time it is not desired to give the impression 
that streptococcic infections are devoid of danger, as they ai( often 
serious and sometimes fatal, and I believe that our favorable results are 
probably attributable to the fact that many mild cases are included in our 
series which would have escaped detection except for the bacteriological 
examination of the lochia in all febrile cases. Nevertheless, our results 


1012 


PUERPERAL INFECTION 


would appear to indicate that too energetic treatment may be harmful, 
and that an equally good or better outcome will follow safer and more 
conservative measures. 

To recapitulate, in dealing with a case of puerperal endometritis after 
having removed some of the uterine lochia for cultures, the uterus should 
be douched with several liters of sterile salt solution. If the bacterio¬ 
logical examination shows the presence of streptococci all local treatment 
is contra-indicated. If, on the other hand, one has to deal with a putrid 
endometritis, and the symptoms do not yield to the first injection, addi¬ 
tional douches may be given. When the infection has extended beyond 
the uterus local treatment will only do harm in acute cases. 

Bumm has redirected attention to the observation made by Guerin in 
1858 that in many instances involution had taken place very incom¬ 
pletely, and he therefore recommended the employment of ergot to secure 
better contraction, thereby occluding to some extent the lymphatics in 
the uterine wall. My own experience is in accord with this view, and 
whenever the uterus is larger than it should be at a given period of 
the puerperium the administration of one-half dram of the fluid extract 
four times a day for 48 hours is indicated. 

In gonorrheal endometritis active treatment is not required at the 
time, since in the vast majority of cases the moderate rise of temperature 
associated with the onset of the disease soon falls to normal, and the 
patients recover spontaneously, or are left with a chronic endometritis 
and disease of the appendages, which can be treated more advantageously 
at a later period. 

In all severe cases general tonic measures that will serve to keep 
up the strength of the patient and increase her resistance to the infec¬ 
tive virus are most valuable. Fresh air, easily digestible food, and fluids 
in large quantity are most important, while the most reliable drugs are 
strychnin and alcohol, and it is a matter of experience that these patients 
usually can bear much larger quantities of the latter than when in health. 
High fevoi should not be combated with antipyretics, the external appli¬ 
cation of cold, either in the form of spongings or cold baths, being 
preferable. Hydrotherapeutic measures have been enthusiastically ad^ 

vocated by Lunge and others, and in their hands have given satisfactory 
results. 

Occasionally, surprisingly good results are obtained in profoundly 
septic conditions by repeated subcutaneous injections of sterile salt solu¬ 
tion. Attention was first directed to this method of treatment by Bose, 
and subsequent experience has to some extent justified his predictions. 

f the process has extended beyond the uterus, and we have to deal 
with a parametritis or a pelvic peritonitis, dry or moist heat to the 
lower portion of the abdomen, in the form of poultices or other hot 
applications, is to be recommended. 

A great deal has been written on the operative treatment of puer- 
peia in ection, nearly every prominent obstetrician and gynecologist 
hawng made some contribution to the subject. Every one is agreed as 

tie advisability of opening parametritic abscesses as soon as fluctua¬ 
tion appears rather than allowing them to rupture spontaneously. Occa- 


CURATIVE TREATMENT 


1013 


sionally in parametritis, on palpation a semifluctuant sensation is con¬ 
veyed to the examining linger which may lead one to imagine that one 
has to deal with pus, whereas upon opening the supposed abscess through 
the vagina or abdominal wall, as the case may be, the tumor turns out 
to be an inflammatory exudate without pus formation, and only a small 
amount of serous fluid escapes. Fortunately, incision into such masses 
frequently gives as good results as if a considerable quantity of pus had 
been evacuated, just as happens in cases of cellulitis elsewhere. 

TV hen pus tubes or ovarian abscesses can be made out by bimanual 
palpation, their removal is indicated, for as long as they remain the 
patient will continue in a septic condition. At the same time it should 
be remembered that in streptococcic infections the bacteria may retain 
their virulence for long periods, so that abdominal operations are much 
more dangerous than at other times. For this reason interference should 
be delayed as long as possible, and in the early part of the puerperium 
should be undertaken only when urgently indicated. Whether such con¬ 
ditions should be dealt with by laparotomy or by puncture through the 
vagina will depend upon the particular case. If they are freely movable, 
laparotomy should be performed; whereas if they are adherent and 
readily accessible from below, vaginal puncture with subsequent packing 
of the abscess cavity with gauze is to be preferred. 

The chief point of discussion concerning the operative treatment of 
puerperal infection lias been as to the advisability of removing the in¬ 
fected uterus. Here the various surgeons take quite opposite views, 
the more radical advocating its prompt removal, while the more con¬ 
servative do not regard this step with favor. 

. For two reasons it would appear that hysterectomy is contra-indi¬ 
cated in the majority of cases. In the first place, if one operates at a 
period sufficiently early to prevent the extension of the process to other 
organs, many uteri will undoubtedly be removed from women who would 
have recovered spontaneously; on the other hand’, if one waits until a 
later period, when other organs have become implicated, the operation 
only hastens the inevitable termination. Nevertheless, there is a re¬ 
stricted field for hysterectomy whenever the process has given rise to 
abscess formation within the uterine walls. Again, in a putrid endo> 
metritis, when all other attempts to check the disease have proved futile, 
the operation would appear to be justifiable, as well as the occasional 
instances in which the infectious process is associated with abnormal 
adherence of the placenta. 

Lusk in 1896 suggested that hysterectomy may sometimes be useful 
in the cases of pyemia in which infected thrombi are carried from the 
uterus to various portions of the body, giving rise to metastatic abscesses 
and to a hectic condition. As a rule, however, the thrombotic process 
has extended far beyond the uterus by the time symptoms appear, and 
consequently its removal is useless. Much more practical is the sug¬ 
gestion of Freund, Trendelenburg, and Bumm, that the thrombosed 
vessels be exposed by laparotomy, and excised or ligated distal to the 
thrombus, as may seem most expedient, just as is done in the case 
of infected thrombi complicating mastoid disease. In 1909 I reported 


1014 


PUERPERAL INFECTION 


five such operations with four recoveries and reviewed the literature up 
to that time; while Miller made a statistical study of the results of the 
operation up to 1916. In appropriate cases I regard the procedure as 
most valuable—an opinion in which Miller concurs. 

Formerly the development of general peritonitis was considered al¬ 
most necessarily fatal, and, therefore, in cases of this character the 
treatment was usually perfunctory. But Sourdille, Kownatski, Leopold, 
Boquel, and others have shown that recovery may occasionally follow 
after freely opening and draining the abdominal cavity. Cragin, on the 
other hand, reported that his results were not encouraging. In my 
experience good results are generally obtained when the infection is due 
to the gonococcus, but almost never when it is due to the streptococcus. 
In view, however, of the almost certainly fatal outcome of expectant 
treatment in the latter, such interference would seem justifiable in very 
exceptional cases. 

In certain cases of infection following criminal abortion Pryor, Robb, 
Sourdille, and others have reported encouraging results following wide 
incision of the posterior fornix and packing Douglas’s culdesac with 
iodoform gauze. In many such cases serous or purulent fluid escapes 
from the incision, so that it would appear that the procedure may be 
of value in preventing a pelvic peritonitis from becoming generalized. 
In my limited experience this procedure has not appeared to exert an 
appreciable influence upon the course of the disease, but in view of the 
high standing of its sponsors it is worthy of trial. 

The prospects of coping more successfully with puerperal infection 
were greatly brightened in 1895 by Marmorek’s announcement of the 
discovery of an antistreptococcic serum. Unfortunately, the results of 
serum therapy in puerperal infection have not proved satisfactory. In 
May, 1899, a committee of the American Gynecological Society, of 
which I was chairman, made an exhaustive report upon the subject, 
giving the complete literature and collecting all the cases treated by 
serum which had been reported up to that time. It was found that 352 
cases had been so treated, with 73 deaths—a mortality of 20.74 per 
cent. In a large number of cases there was considerable doubt as to 
whether the infections were due to the streptococcus; but in 101 cases 
in which its presence was demonstrated the mortality was 32.69 per cent. 

This was a very discouraging showing, especially when compared to 
the results obtained by others without it. The question therefore arose 
as to whether the high mortality was due to the use of the antistrep¬ 
tococcic serum or to other attendant causes. Our investigations having 
indicated that the serum was practically harmless, the poor results fol¬ 
lowing its use can probably be explained in one of two ways: first, that 
many exceptionally severe cases had been treated; and, secondly, that a 
large number of the cases so treated had already been curetted—a pro¬ 
cedure which is often followed by untoward results. In view of these 
facts the committee reported that while there was no evidence in favor 
of the therapeutic value of the serum, it apparently did not exert a dele¬ 
terious effect upon the patient, and therefore might be employed if the 
physician so desired. 


LITERATURE 


1015 


Following the report of our committee the general consensus of 
opinion has been that Marmorek’s serum is practically useless as a 
therapeutic agent in the treatment of puerperal infection. Later Aron- 
sohn, Tavel, Menzer and others have directed renewed attention to the 
subject. They showed that in order to produce an effective serum for 
use in human beings the streptococcus should not be passed through 
lower animals, but that as many strains as possible of virulent strepto¬ 
cocci, obtained from human sources, should be employed for immunizing 
the animal from which the serum is to be obtained. 

It was then shown that the serum did not neutralize the toxins, as 
is the case with antidiphtheritic serum, nor did it directly kill the 
bacteria, but merely gave rise to conditions which favored phagocytosis 
—in other words, increased the opsonic power of the blood. Moreover, 
experimental work has demonstrated that while the serum might possess 
marked prophylactic value and be able to protect an animal against 
inoculation with many times the ordinarily fatal dose of streptococci, 
it is lacking in curative properties, or at most is of value only in the 
initial stages of infection. Modern antistreptococcic serum has been 
employed in large series of cases, but does not appear to have exerted 
an appreciable effect upon the course of the disease, although it has no 
deleterious effect upon the patient. The subject was exhaustively con¬ 
sidered by McLeod in 1914. 

Some hope was entertained that satisfactory results might be ob¬ 
tained by use of bacterial vaccines. Sir Almroth Wright, however, in¬ 
formed me that he had no such expectation as to streptococcic infec¬ 
tions, although improvement might be expected in certain chronic cases 
due to the staphylococcus or gonococcus. A collective investigation by a 
committee of the American Gynecological Society in 1910, has served 
only to confirm his conclusions. At the same time it should be men¬ 
tioned that Polak is more optimistic and believes the use of vaccines is 
sometimes followed by surprising results. 

Reference needs scarcely be made to the employment of intravenous 
injections of formalin, as advocated by Barrows, in 1903, as subsequent 
investigation has shown that they are not only of no value, but are 
absolutely harmful. 

A considerable literature has accumulated upon the employment of 
Crede’s ointment, and the intravenous injection of collargol or a solution 
of silver nitrate in puerperal infection. The report of Osterloh, however, 
shows that they are of but slight value, and act only by promoting 
phagocytosis. 


LITERATURE 

Ahlfeld. Beitrage zur Lehre vom Resorptionsfieber im Wochenbett und von der 
Selbstinfektion. Berichte und Arbeiten, 1883, 165. 

Beitrag zur Lehre der Selbstinfektion. Zentralbl. f. Gyn., 1887, xi, <29. 
Beitrage zur Lehre vom Resorptionsfieber in der Geburt und im Wochenbette und 
von der Selbstinfektion. Zeitschr. f. Geb. u. Gyn., 1893, xxvii, 466-519. 
Aronsohn. Untersuchungen iiber Streptokokken u. Antistreptokokkenserum. Berl. 
klin. Wochenschr., 1902, ii, 979-982, and 1903, 1006-1010. 


1016 


PUERPERAL INFECTION 


Bar et Tissier. Serotherapie dans l'infection puerperale. L 'Obstetrique, 1896, 
97-128, 204-217. 

Bardeleben. Streptococcus u. Thrombose. Archiv f. Gyn., 1907, lxxiii, 1-82. 

Barker. The Puerperal Diseases. 3d ed., 1874. 

Barrows. Intravenous Injection of Formalin Solution for Puerperal Septicaemia. 
Amer. Jour. Obst., 1903, xlvii, 366. 

Blumer. A Case of Mixed Puerperal and Typhoid Infection, in which the Strep¬ 
tococcus and Typhoid Bacillus were isolated both from the Blood and Uterine 
Cavity. Amer. Jour. Obst., 1899, xxxix, 42-50. 

Boehr. Untersuchungen iiber die Haufigkeit des Todes im Wochenbett in Preus- 
sen. Zeitschr. f. Geb. u. Gyn., 1878, iii, 16. 

Bondy. Ueber puerperale Infektion durch anaerobe Streptokokken. Monatsschr. 
f. Geb. u. Gyn., 1911, xxxiv, 536-549. 

Die Bedeutung der Pneumokokken fUr die puerperale Infektion. Zeitschr. f. 
Geb. u. Gyn., 1912, lxxii, 631-644. 

Boquel. Sur le traitement des peritonites aigues au cours de la puerperalite. 
Archives mens, d'obst. et de gyn., 1912, i, 37-58. 

Bose. Injections de serum artificiel dans les maladies infectieuses et les intoxica¬ 
tions. Presse med., 1896, No. 49, 287-290. 

Boxall. The Mortality of Childbirth. Lancet, 1893, ii, 9-15. 

Breuer. Ueber puerperale Pleuritis u. Pneumonie. Chrobak's Festschrift, 1903, 
i, 399-417. 

Brieger. Ueber bakteriologische Untersuchungen bei einigen Fallen von Puer- 
peralfieber. Charite-Annalen, 1888, xiii, 198. 

Brutt. Beitrage zur Kenntniss und zur chirurgischen Behandlung der puerperalen 
Gasbrandinfektion des Uterus. Archiv f. Gyn., 1922, cxvi, 1-25. 

Budin. La Semaine med., 1896, 155. 

Bumm. Die puerperale Wundinfektion. Zentralbl. f. Bakteriol., 1887, ii, 343. 

Histologische Untersuchungen iiber die puerperale Endometritis. Archiv f. Gyn., 
1891, xl, 398. 

Ueber die verschiedenen Virulenzgrade der puerperalen Infektion und die lokale 
Behandlung bei Puerperalfieber. Zentralbl. f. Gyn., 1893, xvii, 975. 

Ueber Diphtherie und Kindbettfieber. Zeitschr. f. Geb. u. Gyn., 1895, xxxiii, 
126-136. 

Ueber die ehirurgische Behandlung des Kindbettfiebers. Sammlung zwangloser 
Abhandlungen aus dem Gebiete der Frauenheilkunde und Geb., 1902, iv, 
Heft 4. 

Bumm u. Sigwart. Untersuchungen iiber die Beziehungen der Streptococcen zum 
Puerperalfieber. Beitrage z. Geb. u. Gyn., 1904, viii, 329-336. 

Burckhardt. Ueber den Einfluss der Scheidenbakterien auf den Verlauf des 
Wochenbettes. Archiv f. Gyn., 1893, xiv, 71-94. 

beber den Iveimgehalt der Uterushohle bei normalen Wochnerinnen. Zentralbl. 
f. Gyn., 1898, xxii, 686-689. 

Puerperal-infektion mit Pneumococcus Fraenkel. Beitrage zur Geb. u. Gyn., 
1901, v, 327-338. 

Burtensiiaw. The Fever of the Puerperium. New York Med. Jour., 1904, 
June 4. 

Lvers. Mortality from Puerperal Fever in England and Wales. Amer. Jour. 
Obst., 1901, xliv, 433-441. 

Chirie. Septicemie a pneumo-bacilles de Friedlander. Bull. Soc. d 'obst. de Paris, 
1906, ix, 357-362. 

Coze et Feltz. Experiences sur le sang de fievre puerperale. Gazette med. de 
Strasbourg, 1869, xxix, 29, 38. 


LITERATURE 


1017 


Cragin. The Treatment of Puerperal Infection. Amer. Jour. Obst., 1906, liii, 
775-791. 

Czemetschka. Pragcr med. Wochenschr., 1894, xix, 233. 

Denzler. Die Bakterienflora des gesunden Genitalkanals des Bindcs, etc. D. I., 
Zurich, 1904. 

Dobbin. Puerperal Sepsis Due to Infection with the Bacillus Aerogenes Capsu- 
latus. Bull. Johns Hopkins Hosp., 1897, viii, 24. 

A Case of Puerperal Infection in which the Bacillus Typhosus was found in the 
Uterus. Amer. Jour. Obst., xxxviii, 185-198. 

Doderlein. Untersuchung iiber das Vorkommen von Spaltpilzen in den Lochien 
des Uterus und der A agina gesunder und kranker Wochnerinnen. Archiv f. 
Gyn., 1887, xxxi, 412. 

Das Scheidensekret und seine Bedeutung fur das Puerperalfieber. Leipzig, 1892. 
A orlaufige Mittheilung iiber weitere bakteriologische Untersuchungen des Schei- 
densekretes. Zentralbl. f. Gyn., 1894, xviii, 779. 

Die Beziehungen der Endometritis zu den Fortpflanzungsvorgangen. Verh. d. 
deutschen Ges. f. Gyn., 1895, 224-242. 

Doderlein und Winternitz. Die Bakteriologie der puerperalen Sekrete. Beitrage 
zur Geb. u. Gyn., 1900, iii, 161-174. 

Doleris. Essai sur la pathogenie et la therapeutique des accidents infectieux des 
suites de couches. These de Paris, 1880. 

Dublin. Mortality Among Women from Causes Incidental to Childbearing. Am. 
Jour. Obst., 1918, lxxviii, 20-37. 

Ehlers. Die Sterblichkeit im Kindbett in Berlin und in Preussen. Stuttgart, 1900. 
Eichel. The Geographical Distribution of Maternal Mortality in New York State. 

New York State Dept, of Health Bulletin, June, 1922. 

Eisenmann. Wund- und Kindbettfieber. Erlangen, 1837. 

Fehling. Ueber Selbstinfektion. Verh. d. deutschen Gesellsch. f. Gyn. Freiburg, 
1889. 

Foulerton and Bonney. An Investigation into the Causation of Puerperal Infec¬ 
tion. Jour. Obst. and Gyn. Brit. Emp., 1905, vii, 121-126. 

Fraenkel. Ueber die Aetiologie u. Genese der Gas-plilegmonen. Lubarsch- 
Ostertag, Ergebnisse der allg. Path. u. path. Anat., 1904, viii, 403-471. 
v. Franque. Bakteriologische Untersuchungen bei normalem und fieberhaftem 
Wochenbett. Zeitschr. f. Geb. u. Gyn., 1893, xxv, 277. 

Franz. Bakteriologische und klinische Untersuchungen iiber leichte Fiebersteiger- 
ungen im Wochenbette. Beitrage zur Geb. u. Gyn., iii, 1900, 51-100. 

Freund. Ueber die Methoden und Indikationen der Totalexstirpation des Uterus. 

Beitrage zur Geb. u. Gyn., 1898, i, 344-404. 

Fromme. Physiologie u. Pathologie des Wochenbettes. Berlin, 1910. 

Galtier. De 1 ’infection primitive du liquide amniotique apres rupture prematuree 
des membranes de l’ceuf humain. These de Paris, 1895. 

Gebhard. Bacterium coli commune aus Fallen von Tympania uteri geziichtet. 

Verh. d. deutschen Gesellsch. f. Gyn., 1893, 305. 

Gide. De 1 ’infection puerperale par le bacille de Loeffler. these de Lyon, 1911. 
Goldsborough. Thrombosis of the Internal Iliac Vein during Pregnancy. Bulle¬ 
tin of the Johns Hopkins Hospital, 1904, xv, 193-196. 

Goldscheider. Klinische und bakteriologische Mittheilungen iiber Sepsis puer- 
peralis. Charite-Annalen, 1893, xviii, 164-242. 

Gordon. A Treatise on the Epidemic Puerperal lever, London, 1795. 

Guerin. Sur la fiev.re puerperale. Bull, de l’acad. de med., Paris, 1858, xxiii, 

766-82. 

Hamm. Welche Aussichten bietet die prophylactische Antiseptik der Scheide, etc. 
Archiv f. Gyn., 1918, cviii, 110-136. 


1018 


PUERPERAL INFECTION 


Harris and Dabney. Report of a Case of Gonorrhoeal Endocarditis in a Patient 
Dying in the Puerperium. Bull. Johns Hopkins Hosp., 1901, xii, 68-76. 

Heiberg. Die puerperalen und pyamischen Processe, 1873. 

Heinricius. Exp. Untersuch, iiber die Einwirkung des Bacillus aerogenes capsu- 
latus. Archiv f. Gyn., 1908, lxxxv, 216-250. 

Heynemann. Der E. Fraenkel’sche Gasbaeillus, etc. Zeitschr. f. Geb. u. Gyn., 
1911, lxviii, 425-443. 

Hirsch. Historisch-pathologische Untersuchungen iiber Puerperalfieber. Er¬ 
langen, 1864. 

Hirst. Some Problems in the Diagnosis and Treatment of Puerperal Infection. 
Amer. Medicine, 1906, xl, 121-123. 

Holmes. Puerperal Fever as a Private Pestilence. Boston, 1855. 

Hornung. Zur Frage der primaren genitalen Pneumokokkeninfektion. Zentralbl. 
f. Gyn., 1920, 850-856. 

Howard. Importance of Bacillus Mucosus Capsulatus (B. Friedlander) as the 
Cause of Acute and Chronic Infections. Philadelphia Med. Jour., 1898, i, 
336-338. 

The Real Risk Rate of Death to Mothers from Causes Connected with Childbirth. 
Am. Jour. Hygiene, 1921, i, 197-233. 

Johnston and Morgan. Acute lobar Pneumonia and Hematogenous Puerperal 
Infection. Bull. Johns Hopkins Hosp., 1922, xxxiii, 106-109. 

Jotten. Ueber die Bedeutung der Streptokokkenbefunde im Vaginalsekret Kreis- 
sender. Zentralbl. f. Gyn., 1912, 1529-1533. 

Kaltenbach. Zur Antisepsis in der Geburtshiilfe. Volkmann’s Sammlung klin. 
Yortrage, Nr. 295. 

Ueber Selbstinfektion. Verh. d. deutsehen Gesellsch. f. Gyn. Freiburg, 1889. 

Kirkland. Treatise on Childbed Fever, 1774. 

Kneise. Zur Kenntniss der reinen Septikamie. Archiv f. Gyn., 1904, lxxiii, 333- 
350. 

Kownatski. Zur Behandlung der freien puerperalen Peritonitis mit Laparotomie 
u. Drainage. Berliner klin. Wochenschr., 1905, Nr. 20. 

Kronig. Vorlaufige Mittheilung iiber Gono.rrhoe im Woehenbett. Zentralbl. f. 
Gyn., 1893, xv, 157. 

Scheidensekretuntersuchungen bei ein Hundert Schwangeren. Aseptik in der 
Geburtshiilfe. Zentralbl. f. Gyn., 1894, xviii, 3-10. 

Ueber Fieber intra-partum. Zentralbl. f. Gyn., 1894, 749. 

Discussion iiber Endometritis. Verh. d. deutsehen Gesellsch. f. Gyn., 1895, 
498-502. 

Klinische Versuche iiber den Einfluss der Scheidenspiilungen wahrend der Geburt 
auf den Wochenbettsverlauf. Miinchener med. Wochenschr., 1900, Nr. 1. 

Kronig und Menge. Bakteriologie des Genitalkanales der schwangeren, kreis- 
senden und puerperalen Frau. Leipzig, 1897. 

Kronig u. Pankow. Zur bakt. Diagnose des Puerperalfiebers. Centralbl. f. Gyn., 
1909, 161-170. 

Lea. Puerperal Infection. London, 1910. 

Lea and Sidebotham. Bacteria of the Puerperal Uterus. Jour. Obst. and Gyn. 
Brit. Emp., 1909, xv, 26-41. 

Lenhartz. Die septischen Erkrankungen. NothnageUs Spec. Path, und Therapie 
1904, iii, Theil 2. 

Leopold. Vergleichende Untersuchungen iiber die Entbehrliclikeit der Scheiden- 
ausspiilungen bei ganz normalen Geburten und iiber die sogenannte Selbstin¬ 
fektion. Archiv f. Gyn., 1894, xlvii, 580-635. 

Zur operativen behandlung der puerperalen Peritonitis u. Pyaemie. Archiv f. 
Gyn., 1906, lxxvii, 1-33. 


LITERATURE 


1019 




Liepmann. Das geburtshilfliche Seminar. Berlin, 1910, 292. 

Little. A Simple Method of Obtaining Uterine Lochia for Bacteriological Ex¬ 
amination. Bull. Johns Hopkins Hospital, 1904, xv, 250-251. 

The Bacillus Aerogenes Capsulatus in Puerperal Infection. Bull. Johns Hopkins 
Hospital, 1905, xvi, 136-146. 

The Bacteriology of the Puerperal Uterus. American Jour. Obst., 1905, lii, 815- 
847. 

Lomer. Ueber den heutigen Stand der Lehre von den Infektionstragern bei 
Puerperalfieber. Zeitschr. f. Geb. u. Gyn., 1884, x, 366. 

Lusk. Recent Bacteriological Investigations concerning the Nature of Puerperal 
Fever. Amer. Jour. Obst., 1896, xxxiii, 337-347. 

Mahler. Thrombose, Lungenembolie u. plotzlicher Tod. Arbeiten aus der 
Frauenklinik in Dresden, 1895, iii, 72-120. 

Marmorek. Sur le streptocoque. Comptes rendus de la soc. de biol., 1895, lOme 
serie, ii, 122. 

Le streptocoque et le serum antistreptococcique. Annales de l’lnstitut Pasteur, 
1895, ix, 593-620. 

Mayrhofer. Zur Frage nach Aetiologie der Puerperalprocesse. Monatsschr. f. 
Geburtskunde, 1865, xxv, 112-134. 

McLeod. On the Value of Antistreptococcal Sera. Lancet, 1914, clxxxvii, 837- 
842. 

Meigs. On Childbed Fever. Philadelphia, 1854. 

Meigs, G. Maternal Mortality in Relation to Childbirth. Bulletin Children's 
Bureau, 1917. 

Menzer. Das Antistreptokokkenserum und seine Anwendung beim Menschen. 

Miinchener med. Wochenschr., 1903, 1057-1061 and 1125-1129. 

Miller. Surgical Treatment of Puerperal Pyemia. Clin. Congress of Surgeons 
of North America. Nov., 1916. 

Mixius. Bakteriologische Untersuchungen einiger Falle puerperaler Sepsis. D. 
I., Berlin, 1892. 

Natwig. Bakteriologische Verhaltnisse im weibl. Genitalsekrete. Archiv f. Gyn., 
1905, lxxvi, 701-859. 

Neumann. Ueber puerperale Uterusgonorrhoe. Monatsschr. f. Geb. u. Gyn., 1896, 
iv, 109-116. 

Nisot. Diphtherie vagino-uterine puerperale. Annales de gyn. et d’obst., 1896, 
xlv, 259. 

Orth. Virchow's Archiv, lviii, 441. 

Osterloh. Beitrag zur Behandlung des Puerperalfiebers mit intravenosen Collar- 
goleinspritzungen. Deutsches Archiv f. klin. Med., 1905, lxxxv, 227-233. 
Pasteur. Septicemie puerperale. Bull, de 1 acad. de med., 1879, 260-271. 
Perkins. Report of Nine Cases of Infection with Bacillus Pyocyaneus. Jour. 
Med. Research, 1901, vi, 281-297. 

Pinard et Wallich. Traitement de 1 'infection puerperale. Paris, 1896. 

Piper. The Treatment of Puerperal Sepsis by the Use of Mercurochrome In¬ 
travenously. Am. Gyn. Soc., 1922, xlvii, 233-246. 

Polak. Two Years' Experience with Vaccines in Pelvic Infections. Jour. Am. 

Med. Assn., Nov. 25, 1911. 

Pryor. Treatment of Puerperal Streptococcus Infection by Curettage, the Cul- 
de-sac Incision, etc. Amer. Jour. Obst., 1889, xxxix, 584-596. 
Recklinghausen. Zentralbl. f. med. Wissenschaften, 1871, 713. 

Richter. Thrombose u. Embolie im Wochenbett. Archiv f. Gyn., 1905, lxxcv, 

122-142. 

Robb. The Vaginal Incision in Sepsis following Abortion. Amer. Gyn., 1903, ii, 
524-530. 




1020 


PUERPERAL INFECTION 


Runge. Die Allgemeinbehandlung der puerperalen Sepsis. Archiv f. Gyn., 1888, 
xxxiii, 39-52. 

Sackenreiter. Die E.rreger der putriden Endometritis. Beitrage z. Geb. u. Gyn., 
1912, xvii, 246-276. 

Schmidlechner. Gangraena uteri puerperalis (Metritis dessicans). Archiv f. 
Gyn., 1906, lxxviii, 525-538. 

Scilottmuller. Zur Bedeutung einiger Anaeroben in der Pathologie, insbesondere 
bei puerperalen Erkrankungen. Mittheil. aus den Grenzgebieten der Med. 
u. Chir., 1910, xxi, 450-490. 

Semmelweiss. Die Aetiologie, der Begriff u. die Prophylaxis des Kindbettfiebers. 
Pest, Wien u. Leipzig, 1861. 

Sigwart. Die Streptokokken-forsehung, etc. Monatsschr. f. Geb. u. Gyn., 1910, 
xxxi, 486-496. 

Silberschmidt. Historisch-kritische Darstellung der Pathologic des Kindbett- 
fibers, Gekronte Preissschrift. Erlangen, 1859. 

Sitsinsky. Die Behandlung des septischen Wochenbetterkrankungen. Monats¬ 
schr. f. Geb. u. Gyn., 1904, xx, Erganzunsheft, 640-677. 

Smith. Severe Puerperal Sepsis Due to Gonococcus Infection. Cleveland Med. 
Jour., 1911, x, 810-818. 

Sourdille. Traitement de l’infection puerperale grave par la laparotomie ou 
par la colpotomie sans hysterectomie. Revue de gyn., 1905, ix, 857-890. 

Stolz. Studien zur Bakteriologie des Genitalkanales in der Schwangerschaft u. 
im Wochenbett. Beitrage z. Geb. u. Gyn., 1903, vii, 406-421. 

Stone and McDonald. The Gonococcus in the Puerperium. Surg. Obst. and Gyn., 
1906, ii, 151-162. 

Strauss et Sanchez-Toledo. Septicemie puerperale experimentale. Nouv. 
archives d’obst. et de gyn., 1S89, cv, 277-295. 

Strother. Critical Essay on Fevers. London, 1718. 

Taussig. Gonorrhoeal Puerperal Infection. Amer. Gyn., 1903, ii, 334-345. 

Tavel. Exp. u. klinisches iiber das Antistreptokokkenserum. Deutsche med. 
Wochenschr., 1903, Nr. 50. 

Trendelenburg. A Review of Surgical Progress. Jour. Am. Med. Assn., 1906, 
xlvii, 81-83. 

Vignal. Sur Faction des micro-organismes de la bouche et des matieres fecales. 
Comptes rendus de la soc. de biol., aout, 1887. 

Waldeyer. Ueber das Yorkommen von Bakterien bei der diphtheritischen Form 
des Puerperalfiebers. Archiv f. Gyn., 1872, iii, 293. 

Waltiiard. Bakteriologische Untersuchungen des weiblichen Genitalsekretes in 
der Graviditat und in Puerperium. Archiv f. Gyn., 1895, xlviii, 201-269. 

Walthard u. Reber. Beitrage zur Kenntniss der Natur u. klin. Bedeutung der 
Vaginalstreptokokken. Zeitschr. f. Geb. u. Gyn., 1905, liv, 304-442. 

Wauschkuhn. Ueber das Yorkommen von echten Diphtheriebazillen bei Gebaren- 
den und Neugeborenen. Zentralbt. f. Gyn., 1920, 820-824. 

Welch. Morbid Conditions caused by Bacillus Aerogenes Capsulatus. Boston 
Med. and Surg. Jour., 1900, cxliii, 73-87. 

Wetherill. The Rational Treatment of Puerperal Infection. Amer. Jour. Obst., 
1903, xlvii, 590-598. 

Widal, fitude sur 1 ’infection puerperale. These de Paris, 1889. 

Infection puerperale et phlegmasia alba dolens. Gaz. des Hop., 1889, 565. 

Williams. Puerperal Infection considered from a Bacteriological Point of View, 
with Special Reference to the Question of Auto-infection. Amer. Jour. Med. 
Sciences, July. 1893. 

The Cause of the Conflicting Statements concerning the Bacterial Contents of 













LITERATURE 


1021 


the Vaginal Secretion of the Pregnant Woman. Amer. Jour. Obst., 1898, 
xxxviii, 807-817. 

The Bacteria of the Vagina and their Practical Significance, based upon the 
Bacteriological Examination of the Vaginal Secretion in Ninety-two Pregnant 
Women. Amer. Jour. Obst., 1898, xxxviii, 449-483. 

Diphtheria of the Vulva. Amer. Jour. Obst., 1898, xxxviii, 180-185. 

Ein Fall von puerperaler Infektion, bei dem sich Typhusbacillen in den Locliien 
fanden. Zentralbl. f. Gyn., 1898, xxii, Nr. 34. 

Ligation and Excision of Thrombosed Veins in the Treatment of Puerperal 
Pyaemia. Am. Jour. Obst., 1909, lix, 758-789. 

Williams, Cragin, and Newell. Report on the Employment of Vaccine Therapy 
in Gynecology and Obstetrics. Surg. Gyn. and Obst., 1910, x, 12-19. 

Williams, Pryor, Fry, and Reynolds. The Value of Antistreptococcic Serum 
in the Treatment of Puerperal Infection. Trans. Amer. Gyn. Soc., 1899, 
xxiv, 80-126. 

Winter. Ueber Selbstinfektion. Zentralbl. f. Gyn., 1911, 1495-1505. 

Zangemeister u. Kirstein. Zur Frage der Selbsinfektion. Archiv f. Gyn., 1915, 
civ, 1-27. 






CHAPTER XLIV 


DISEASES AND ABNORMALITIES OF THE PUERPERIUM 

We have already discussed in detail the more typical instances of 
puerperal infection. We shall now take up certain atypical varieties— 
tetanus, phlegmasia alba dolens, and cystitis—and shall then proceed to 
consider certain other diseases and abnormalities which may be en¬ 
countered in the puerperium, but which are not due to the introduction 
of infective material into the genital tract. Thus, we shall find that 
fever, associated with constitutional disturbances, is frequently met with 
as the result of pathological conditions in the breasts, disorders of the 
intestinal tract, and in very rare instances may be due to emotional 
causes. Moreover, it must be remembered that Nature has not rendered 
the puerperal woman exempt from the various disorders from which she 
might suffer at other times. 

Tetanus.—The undoubted development of tetanus during the puer- 
perium, although a very rare occurrence, has been fully established by 
the researches of Chantemesse and Widal, of Heyse, of Rubeska, and 
of others, who have isolated the characteristic bacilli from the uterine 
lochia. Spiegel in 1914 was able to collect 64 cases from the literature. 
The infection usually follows gross errors in aseptic technic, especially 
during operative procedures. Thus, in several of the reported cases, it is 
recorded that the operator placed the forceps upon the dirty floor by the 
side of the bed, and afterward carried it directly to the genital tract of 
the patient. Occasionally, however, such an explanation cannot be ad¬ 
duced, as in an epidemic in the Prague Lying-in Hospital, the disease, 
in one instance, at least, occurred in a woman who had not even been 
examined internally. 

Tetanus follows abortion more frequently than full-term labor, and 
as a rule gives rise to untoward manifestations between the sixth and 
tenth days of the puerperium, and sometimes later, though in rare in¬ 
stances the first symptom has been known to appear before the completion 
of labor. The prognosis is very grave. All of the 20 patients mentioned 
by Rubesca succumbed, while Vinay reports a similar result in 94 out 
of the 106 cases included in his statistics. 

Beyond affording means for temporarily controlling the symptoms, 
therapeutic measures are valueless, although the intralumbar injection 
of from 5 to 10 cubic centimeters of a 15 per cent, solution of magnesium 
sulphate is highly efficient in suppressing the convulsive seizures. Thus 
far the results obtained from the employment of antitetanic serum have 
not been encouraging, although its prophylactic employment has been 
attended by excellent results. In view of the hopelessness of other lines 

1022 


THROMBOSIS OF VESSELS OF LOWER EXTREMITIES 1023 


of treatment, Pawlik and Rubeska removed the uterus in several of their 
cases, but without avail. 

Thrombosis of the Vessels of the Lower Extremities.—Thrombosis 
occurring in the crural, saphenous, or popliteal veins— Phlegmasia alba 
dole ns —is usually a manifestation of puerperal infection, and follows the 
direct extension of a thrombotic process from the pelvic veins; occa¬ 
sionally it results from a localized phlebitis or periphlebitis, and in very 
rare instances may be due to purely mechanical factors. The lumina 
of the large veins rarely undergo complete obliteration, so that the cir¬ 
culation, while markedly interfered with, is not completely shut off. 

Symptoms do not usually make their appearance until the latter part 
of the second week of the puerperium, or even later. In most cases the 
first manifestation is pain in one leg extending along the course of one 
of the larger veins; this is soon followed by edema, which usually begins 
in the foot and extends upward, although occasionally it appears first 
in the neighborhood of the groin. The leg soon becomes much swollen, 
the skin being tightly stretched and presenting a glazed appearance, but 
at first pitting can be elicited only after prolonged pressure with the 
finger-tip. If the crural vein is implicated, a very sensitive cordlike 
structure can often be palpated just beneath Poupart’s ligament and 
can be followed for a certain distance down the thigh. 

The inflammatory changes are usually attended by some elevation of 
temperature, the pulse being more or less accelerated. High fever and 
a very rapid action of the heart usually indicate that similar processes 
exist in other portions of the body, and that the patient is suffering from 
a more generalized thrombophlebitis. In uncomplicated cases the pain, 
swelling, and temperature may continue for several weeks, and then 
gradually subside, though occasionally months elapse before the patient 
regains the full use of the leg. 

Ordinarily, the process is limited to one side, more rarely both ex¬ 
tremities are affected, an interval of a week or ten days elapsing before 
the second leg becomes implicated. If properly treated, most cases 
undergo spontaneous cure, the condition being dangerous only when it 
forms part of a generalized process, or when the thrombus undergoes 
suppuration and softening, so that infected particles are carried to other 
parts, giving rise to metastatic abscesses. Occasionally the casting off of 
fragments lead to sudden death from pulmonary embolism. 

Treatment .—Complete rest is absolutely essential. The lower part 
of the leg should be elevated, and the entire member encased in absorb¬ 
ent cotton and protected from the weight of the bedclothes by a suitable 
contrivance. If the pain is severe morphin may be requiied, though 
ordinarily the application along the couise of the thiombosed vein of 
cloths soaked in lead water and opium is followed by marked relief. 
Excellent results have been reported from painting the leg with a 15- or 
20-per-cent, solution of ichthyol. 

On account of the danger of detaching portions of the thrombus, the 
leg should never be massaged. The patient should be kept in a horizontal 
position for at least a week after the temperature has subsided, and 




1024 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 

after being allowed to get up she should be cautioned against making 
sudden movements. 

Small varicose veins of the lower extremities sometimes undergo 
spontaneous thrombosis during pregnancy, but more often during the 
first weeks of the puerperium. In pregnancy this occurrence is favored 
by the interference with the circulation due to the pressure exerted by 
the uterus upon the vessels returning from the extremities. During the 
puerperium its development may be incident to pressure exerted upon 
the intrapelvic veins by inflammatory exudates. This form of thrombosis 
is usually unattended by symptoms, although now and again the develop¬ 
ment of a localized phlebitis or periphlebitis may cause pain, and ex¬ 
ceptionally eventuate in the formation of a small abscess. 

Gangrene of the Extremities.—In very rare instances, as the result 
of extensive thrombosis of the venous channels or of embolism of the 
arteries, the circulation in the extremities may become so impaired that 
gangrene results. This accident, first described by Churchill and studied 
more particularly by Wormser and Burckhard, is a most serious com¬ 
plication, and usually ends fatally. Wormser, in 1904, collected 80 
cases from the literature, 6 of which were apparently examples of Ray¬ 
naud’s disease, while of the remainder 66 cases occurred in puerperal, 
as compared with 6 in pregnant, women. Idle process usually involves 
one or both feet, although the hand or forearm may occasionally be 
implicated. Sixty-two per cent, of the 34 patients mentioned in Lafond’s 
thesis died, in spite of the fact that in several instances amputation was 
resorted to in order to check the further development of the process. 

Diseases of the Drinary Tract.—A cystitis occurring during the puer¬ 
perium i^ usually the result of infection following catheterization, during 
which the rules of asepsis have not been scrupulously followed. The 
occurrence of the condition is favored by the presence of slight lesions 
of the vesical mucosa which frequently accompany easy and spontaneous 
labors, and are almost universally associated with difficult deliveries. 
In rare instances it results from the direct extension of areas of in¬ 
flammation about the urethral orifice and vulva. 

In view of the constant presence of bacteria in' the normal urethra, 
and of the impossibility of thoroughly disinfecting the vulva and urethral 
orifice, cystitis will occasionally occur, despite the most rigid precautions. 
For this reason catheterization should be restricted to the greatest pos¬ 
sible extent, and employed only when the patient is unable to evacuate 
the bladder after being placed in a sitting position. As long as it is 
continued, 10 grains of hexamethylenamin should be administered four 
times a day as a prophylactic measure. 

As the process demands a certain period of incubation, symptoms do 
not usually appear for several days. The patient first experiences a 
frequent desire to micturate, but passes only a small quantity of urine 
at one time, the act being accompanied by a burning sensation in the 
urethra, and a tendency to tenesmus afterward. At the same time, 
the bladder and the urethra become sensitive on pressure. The urine 
is usually cloudy, and upon microscopic examination is found to be loaded 
with mucus, leukocytes, epithelial cells, and bacteria. Occasionally it 



HEMORRHAGES DURING THE PUERPERIUM 


1025 


contains a large proportion of blood. The acid reaction is usually re¬ 
tained, although, more especially when the process is prolonged, the 
secretion may become alkaline, and very offensive in odor. Now and 
again cases are encountered in which the infection is so severe that 
larger or smaller portions of the mucosa become exfoliated and are cast 
off with the uterine, their expulsion being associated with cramplike 
pains. 

In these virulent types, as well as in the milder but obstinate proc¬ 
esses, the disease tends to extend up the ureters and to involve the pelvis 
of the kidney, giving rise to a 'pyelitis, which may be followed in a 
few weeks by a pyelonephritis or a pyelonephrosis. Thus, it sometimes 
happens that a patient, who had apparently recovered from a cystitis, 
may suddenly experience intense pain in one renal region, associated with 
the development of a temperature characterized by marked remissions 
and the passage of large quantities of urine laden with pus. The con¬ 
dition frequently apparently passes off to recur again when least expected. 

In mild cases of cystitis the treatment consists in the ingestion of 
large quantities of fluid, particularly milk and the carbonated and 
alkaline waters. The vesical irritability is often satisfactorily allayed 
by the administration of 10-grain capsules of hexamethylenamin repeated 
every four to six hours. Ordinarily, simple treatment leads to recovery 
in a comparatively short time, but if the process drags on, daily irri¬ 
gation of the bladder with a 2-per-cent, solution of boric acid or a 
very weak solution of silver nitrate should be practiced. 

Most cases of pyelitis recover spontaneously after rest in bed and 
the administration of large quantities of fluids and enough sodium bi¬ 
carbonate to render the urine alkaline; but whenever a pyelonephritis 
is accompanied by prolonged febrile manifestations, drainage and occa¬ 
sionally extirpation of the organ may be required, although this is 
fortunately rarely necessary. 

Retention of Urine .—In Chapter XYI, upon the care of the patient 
during the puerperium, reference was made to the retention of urine, 
which frequently causes annoyance during the first few days of that 
period. 

Incontinence of Urine .—In multiparous women, during the early 
part of the puerperium, coughing, sneezing, or other factors leading to 
a sudden increase in the intra-abdominal pressure often produce an 
involuntary discharge of a small quantity of urine. The condition usually 
passes off spontaneously, but cure is sometimes hastened by the admin¬ 
istration of 1/30 grain of strychnia four times a day. 

More marked incontinence at this time is usually the result of lesions 
about the neck of the bladder following operative delivery, though when 
the condition does not manifest itself until late in the first week it is 
usually the first sign of the development of a vesicovaginal fistula. In 
this event, scrupulous attention to cleanliness will frequently be followed 
by spontaneous recovery; but when the fistulous opening persists, a 
cure can be effected only by operative procedures at a later peiiod. 

Hemorrhages during the Puerperium.— Ordinarily, if there has been 
no serious loss of blood during the first hour or houi and a half following 


1026 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


delivery, it may be assumed that the danger of postpartum hemorrhage 
has passed. Occasionally, however, in the latter part of the first week, 
and more often still later in the puerperium, more or less severe uterine 
hemorrhages are encountered. They are nearly always due to the re¬ 
tention of portions of a placental cotyledon or of a succenturiate lobule, 
which may have been overlooked at the time of labor. If the retained 
tissue is not cast off spontaneously or removed manually, it undergoes 
gradual necrosis, while at the same time fibrin becomes deposited about 
its periphery, giving rise to a polypoid growth of varying size— placental 
polyp —which, so interferes with the involution of the adjacent portion 
of the uterus that bleeding continues so long as it remains in utero. 

The retention of large portions of the foetal membranes rarely gives 
rise to serious hemorrhage, as the tissues gradually disintegrate and are 
cast off with the lochial discharge. The presence of a remnant of decidua 
of any considerable size, which has failed to undergo the usual regressive 
changes, may act as an irritant upon the regenerating endometrium, 
giving rise to a hyperplasia which is designated as endometritis decidua 
postpartum or postabortum, according as it follows full-term labor or 
abortion. It usually interferes with the process of involution, and may 
lead to more or less hemorrhage. 

The diagnosis of the retention of a placental remnant or the existence 
of a polyp can only be verified by the sense of touch. Therefore, when¬ 
ever a patient suffers from an acute loss of blood during the puerperium, 
the interior of the uterus should be carefully palpated, and any abnormal 
tissue promptly removed by means of the finger or curette. 

The treatment of the slight hemorrhage following retroflexion and 
subinvolution of the uterus will be referred to under those headings. 
The loss of blood associated with an endometritis postpartum demands 
curettage. If the patient bleeds excessively after the expulsion of an 
hydatidiform mole, similar treatment is indicated. And, on account 
of the possibility of the development of a chorio-epithelioma, the tissue 
removed should be subjected to careful microscopic examination. 

Puerperal Hematoma .—A tumefaction resulting from the escape of 
blood into the connective tissue beneath the skin covering the external 
genitalia or the vaginal mucosa is known as a vulval or vaginal hema¬ 
toma. This condition, first studied in detail by Deneux, in 1830, is a 
rare complication of labor and the puerperium, occurring about once in 
1,500 or 2,000 cases. It occasionally originates during pregnancy, and 
may attain such proportions as to interfere with the descent of the 
child. Very exceptionally, if medical aid is not available, fatal hemor¬ 
rhage may follow its rupture at the time of labor, as in the cases reported 
by Kiinzig and others. The condition usually follows injury to a blood 
vessel during the act of labor without laceration of the superficial tissues, 
and may follow spontaneous, as well as operative, delivery. Now and 
again it does not occur until later, and is then attributable to the 
sloughing of a vessel which had become necrotic as the result of pro¬ 
longed pressure. 

Less frequently the torn vessel lies above the pelvic fascia. In this 
event the hematoma develops above it, and in its early stages gives rise 






HEMORRHAGES DURING THE PUERPERIUM 


1027 


to a rounded or sausage-shaped tumefaction, which projects into the 
upper portion of the vaginal canal and may completely occlude its 
lumen. If the bleeding continues, it spreads apart the broad ligament 
and separates the peritoneum from the adjacent tissues. In this way the 
effused blood may form a tumor palpable above PouparUs ligament, or 
it may make its way into the iliac fossae, gradually invade the renal 
region and eventually reach the lower margin of the diaphragm. 

Vulval hematomata of moderate size are usually absorbed spontane¬ 
ously. In other cases the tissues covering the tumor may undergo pres¬ 
sure necrosis and give way, profuse hemorrhage resulting, or the contents 
may be discharged in the form of large clots. In either event the interior 
of the hematoma is very prone to become infected, the condition some- 
I times ending fatally. If the tumor is large, it not only causes discom- 
fort by its mere size, but gives rise to great suffering, which becomes more 
intense the more rapidly it is formed, as the result of the tearing and 
; stretching of the tissues. 

In the subperitoneal variety such quantities of blood may be effused 
beneath the peritoneum that the patient rapidly succumbs to acute 
anemia. In other cases a fatal issue follows secondary rupture into the 
peritoneal cavity. Occasionally rupture occurs into the vagina, in which * 
| event the hematoma becomes infected, the patient may perish if suitable 
1 treatment is not promptly instituted. In 33 cases of subperitoneal 
hematoma which I collected in 1904 the mortality was 56 per cent. It 
is interesting to note that more than 60 per cent, of the cases occurred 
in primiparae, and 71 per cent, after spontaneous labor. In my patient 
the hemorrhage came from a vessel at the base of the bladder, which 
had become torn through during the course of a spontaneous labor. 

A vulval hematoma is readily diagnosticated by the sudden appear¬ 
ance of a tense, elastic, fluctuating, and sensitive tumor of varying size, 
covered by discolored skin. When the mass develops in the vagina it 
may escape detection for a time, but the development of pressure symp¬ 
toms soon leads to a vaginal examination, when a round, fluctuant tumor 
is found, which encroaches upon the lumen. On the other hand, when 
the hematoma extends upward between the folds of the broad ligament, 
it is liable to escape detection, unless it gives rise to a tumor which can 
be felt upon abdominal palpation, or symptoms of anemia or infection 
appear. In my case the uterus was displaced upward by the effused 
blood, and on bimanual examination a fluctuant tumor of 15 centimeters 
in diameter could be palpated beneath it. Had the condition not been 
recognized until after infection had occurred, the differential diagnosis 
between it and an extensive pelvic inflammatory mass would have been 
very difficult. 

The prognosis is usually favorable, though very large hematomata 
occasionally lead to death from hemorrhage, whereas in rare cases the 
fatal termination is the result of infection. 

Treatment .—Small hematomata should be left alone, as spontaneous 
resorption usually takes place, provided the parts be kept clean and 
infection avoided. On the other hand, a steady increase in size indicates 
a continuance of hemorrhage, and in such cases the tumor should be laid 







1028 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


widely open and packed with gauze. The strictest antiseptic precautions | 
are imperative, inasmuch as infection is a frequent complication. In ! 
large subperitoneal hematomata, accompanied by acute anemia, lapa¬ 
rotomy should be promptly performed, the blood clots removed, ant I 
the hemorrhage controlled by ligature or by packing the cavity witl i 
gauze. 

Diseases and Abnormalities of the Uterus. — Subinvolution .—This 
term is used to describe an arrest or retardation of the process of invo¬ 
lution, by which the puerperal uterus is normally restored to its original i 
proportions. 

Involution is the result of an autolytic process, which leads to atrophy I 
of the individual muscle cells, rather than to fatty degeneration, as was I 
formerly supposed. Its proximate cause is to be sought in the liberation j 
of certain, as yet unknown, ferments associated with the sudden and . 
marked diminution of the blood supply to the uterus. As this can be ■ 
brought about only by satisfactory contraction and retraction of the i 
organ, it is apparent that any interference with the process may be j 
followed by subinvolution. 

Among the most frequent factors concerned in its production are \ 
imperfect exfoliation of the decidua, retention of portions of the after^ 
birth, inflammatory lesions of the endometrium, the presence of myoma- ; 
tous nodules in the uterine wall, abnormalities of circulation which 
accompany displacements of the uterus, existence of pelvic inflamma¬ 
tory lesions, and insufficient rest during the puerperium. In other 
words, subinvolution is the result of local conditions and not of consti¬ 
tutional disorders. Accordingly, careful investigation will usually reveal 
the underlying cause, and appropriate treatment, if undertaken suffi¬ 
ciently early, will lead to its cure. 

The existence of subinvolution is manifested by a prolongation of the 
lochial discharge beyond the usual period, its cessation being followed by 
persistent leucorrhea with pains in the back, a general feeling of draggi- 
ness, and a delayed return to perfect health. Similar symptoms accom¬ 
pany uterine displacements, but in all probability are in great part due 
to the coincident subinvolution. If the condition is not properly treated 
it may lead to permanent changes in the uterus, which are sometimes 
associated with such serious hemorrhage as eventually to necessitate the 
removal of the organ. According to R. F. Smith, and Otto Schwarz, 
such uteri are abnormally large, contain much more fibrous and less 
muscular tissue than normally, while the arterial walls are so altered 
that the normal mechanism for the regulation of the circulation is in 
abeyance. 

The diagnosis is established by bimanual examination, the uterus 
being found to be larger, softer, and more succulent than it should 
be at a gi\en time following delivery. Inasmuch as subinvolution is 
dependent mainly upon local conditions, very little can be expected from 
medicinal tieatment, although the administration of a half dram of the 
fluid extract of ergot every three or four hours, together with copious 
hot \ aginal douches, for several days is sometimes folloAved by improve¬ 
ment. Local measures afford much better results. If the uterus is 






DISEASES AND ABNORMALITIES OF THE UTERUS 


1029 


displaced it should be put in proper position by bimanual manipulation 
and held in position by a suitably fitting pessary. When disease of the 
endometrium or retention of portions of the after-birth is responsible, 
prompt curettage offers the most efficient method of treatment. On the 
other hand, procrastination may lead to serious results, as the subinvo¬ 
lution may become permanent. 

Lactation Atrophy of the Uterus. —Ordinarily, in women who suckle 
their children, the uterus may undergo excessive involution, so that 
several months after delivery it may be smaller than in the virginal 
state. This condition is attributed to reflex irritation emanating from 
the breasts and incident to lactation and nursing. It usually disappears 
spontaneously after weaning, though when the child is nursed for a 
longer period than usual the uterus may begin to increase in size before 
the end of a year, even though lactation be continued. It is probable 
that the cessation of menstruation, which is usually observed during 
the early months of lactation, should be partly attributed to this form 
of atrophy. 

Lactation atrophy was first definitely described by Jacquet, in 1871, 
and since the publication of his paper has been carefully studied by 
numerous investigators, particularly Thorn, Gottschalk, Doderlein, and 
Yineberg. In rare instances it may persist after weaning and become 
permanent, the uterine cavity sometimes measuring only a few centi¬ 
meters in length. This abnormality, first described by Chiari, Braun, 
and Spaeth, in 1855, was later designated by Simpson as superinvolution. 
It is probable that it may occasionally be the causative factor in the 
production of future sterility, as well as in the unusually early appear¬ 
ance of the menopause. 

Displacements of the Uterus. —Immediately following the birth of 
the child, the lower uterine segment and cervix are represented by a 
i flabby, collapsed structure which is freely movable upon the rest of 
the organ (see Fig. 328). In these circumstances a comparatively trivial 
cause, such as a slight increase in the intra-abdominal pressure or dis¬ 
tention of the rectum, may lead to an excessive bending forward of 
the body of the uterus— anteflexion. The condition is usually without 
significance, but occasionally the angle formed between the upper and 
lower portions of the organ may be so acute as to occlude the cervical 
canal and lead to the retention of the lochial discharge— lochiometra. 
As a rule the retention, when it occurs, is only transitory, but if it be 
prolonged the lochia may undergo putrefactive changes, when the absorp¬ 
tion of toxins may give rise to constitutional symptoms. The compli¬ 
cation is readily overcome by allowing the retained discharge to drain 
away through a douche-tube, after which the uterine cavity should be 

irrigated with sterile salt solution. 

So long as the body of the uterus lies above the superior strait, 

retrodisplacement cannot occur, as the falling backward of the enlarged 
fundus is prevented by the promontory of the sacrum. But as soon as 
the organ has become sufficiently involuted to descend into the pelvic 
cavity a retroflexion or retroversion becomes possible. The development 
of such displacements, which are rarely observed before the third week 




1030 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


of the puerperium, is probably connected with excessive relaxation of 
some of the structures about the base of the broad ligaments, and appar¬ 
ently results from their overdistention by the presenting part. It is by 
no means always due to trauma incident to operative procedures, as in 
my experience retroflexion quite as frequently follows normal spontaneous 
labor during which no apparent injury was sustained. In other cases the 
retroflexion merely represents a recurrence of a similar condition existing 
prior to pregnancy, while occasionally it may be the result of extreme 
distention of the bladder. 

Backward displacement of the uterus rarely give rise to symptoms 
so long as the patient remains in bed, but as soon as she begins to move 
about their presence is apt to cause more or less inconvenience. The 
earliest and the most characteristic manifestation is an increase in the 
amount of lochial discharge or its reappearance if the flow has already 
ceased. Sometimes the patient suffers from pain in the back and lower 
abdomen, although in other cases she may only be conscious that she 
is not regaining her strength as rapidly as she had expected. In many 
instances, however, the displacement does not give rise to symptoms, so 
that the patient may have no idea of its existence until it is detected 
during the course of a pelvic examination months or years later. In 
my experience such displacements occur in every fourth or fifth puerperal 
woman. Lynch considered the subject in detail in 1922. 

A positive diagnosis can always be made upon vaginal examination, ; 
when the displaced uterus will be found to be larger and softer than 
normal—in other words, the condition is usually associated with sub¬ 
involution. 

The restoration of the uterus to its normal ])osition by bimanual 
manipulations, and the introduction of a properly fitting pessary, as a 
rule will afford prompt relief, and on removal of the pessary three or 
four months later it will frequently be found that a permanent cure has 
resulted. On the other hand, if the pessary is not employed until after 
the conclusion of the puerperium, much less favorable results are ob¬ 
tained, while if deferred until some months later its employment is 
usually useless. This fact serves again to emphasize the necessity for 
making a final examination before discharging the puerperal patient. 
When the patient has suffered from retroflexion before pregnancy, a 
pessary should be introduced on the tenth day of the puerperium, before 
the uterus has returned to its abnormal position. Better results are 
obtained in this way than if the uterus is allowed to undergo involution 
in a retroflexed position; but in either event the prospects of a permanent 
cure are questionable. 

Relaxation of the Vaginal Outlet and Prolapse of the Uterus. —Refer¬ 
ence has already been made to the frequent occurrence of perineal lacera¬ 
tions at the itme of labor and the consequent relaxation of the vaginal 
outlet which follows neglect to repair them. 

Moreover, the changes following childbearing predispose to the 
occurrence of prolapse of the uterus , and an exacerbation should be 
expected during the puerperium in women who have presented moderate 
degrees of descensus uteri before labor. In order to obtain the best 









OBSTETRICAL PARALYSES 


1031 


results, and to prevent serious disability, an early operation is impera- 
ti\e, since the difficulty of rectifying the condition depends largely upon 
the extent of the prolapse and the length of time that it has been 
allowed to exist. 

Delayed Chloroform Poisoning.—Until very recently it was generally 
held that chloroform could be administered with impunity to the woman 
in labor. We now know that this is not the case, but that in rare 
instances symptoms of poisoning may set in several days after delivery 

and lead to death. 

The investigation of Howland and Richards, and Whipple upon 
pregnant dogs shows that the process consists essentially in an autolysis 
of the hepatic cells, which may lead to almost total destruction of the 
secretory portion of the liver. In extreme instances the cells occupying 
the center of each lobule are completely destroyed, so that only a 
margin of approximately normal cells is preserved at the periphery. 
Associated with these changes is a pronounced perversion of metabolism. 

I have encountered the complication upon several occasions, and in 
one instance it ended fatally. This occurred in a primaparous woman 
whose cervix was dilated manually and forceps applied on account of 
threatened foetal asphyxia. The anesthetic was taken badly and was 
given for a little over one hour. The patient was in excellent condition 
for two days, but on the third day jaundice developed, and she passed 
into a torpid state, with occasional periods of excitement, and died in 
coma on the fifth day. At autopsy the liver presenting an appearance 
similar to that observed in the early stages of acute yellow atrophy of 
the liver, and identical with that produced experimentally in dogs. 

Ho doubt such cases were occasionally observed in the past, when 
death was attributed to some obscure toxemia. In view of our present 
knowledge it behooves us to inquire whether we are justified in continu¬ 
ing to use chloroform as an anesthetic. I believe that it may be safely 
employed for ordinary obstetrical anesthesia, but that it should be re¬ 
placed by ether whenever the operation and its preliminary preparations 
promise to last for longer than one half hour. 

Obstetrical Paralyses.—Paralytic conditions may develop in either 
mother or child during the puerperium. That branches of the sacral 
plexus sometimes suffer from pressure during labor is demonstrated by 
the fact that many patients complain of intense neuralgia or of cramplike 
pains extending down one or both legs as soon as the head begins to 
descend into the pelvic canal. As a rule, of course, the compression is 
rarely severe enough to give rise to grave lesions. In some instances, 
however, the pain continues after delivery, and is accompanied by the 
development of paralysis in the muscles supplied by the external popliteal 
nerve_the flexors of the ankles and the extensors of the toes—the 

S gluteal muscles occasionally becoming affected to a lesser extent. 

The subject has been carefully studied by Hiinermann, II. M. 
Thomas, and Hosslin. The investigations of the former supplied a very 
satisfactory explanation of the common localization of the paialysis bv 
showing that the external popliteal nerve receives fibers from the fourth 
and fifth lumbar roots, and that these on their way downward to join 







1032 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 

the sacral plexus pass over the brim of the pelvis, where they are exposed 
to danger from compression, whereas the lower roots which lie upon 
the pyriformis muscle are more protected. 

Hiinermann considers that the chances of injurious pressure are 
greatest where the pelvis is generally contracted, and less so in the 
flattened varieties, inasmuch as the projecting promontory in the latter 
tends to prevent the head from coming in contact with the nerves. In 
the majority of cases the injury is the result of direct pressure exerted 
by the child’s head, and only exceptionally by the forceps. 

In view of the fact that only one oblique diameter of the superior 
strait is occupied by the greatest diameter of the head, it is readily 
understood why the paralysis is usually limited to one leg, Thomas’s 
case being the only instance in which both legs were affected, which had 
been recorded up to 1900. The paralytic symptoms usually appear 
immediately after delivery, and may become permanent unless suitable 
therapeutic measures, more particularly the use of electricity, are 
promptly instituted. 

In other cases paralytic symptoms, accompanied by intense neuralgic 
pains along the course of the sciatic nerve, follow pelvic inflammatory 
troubles. The condition is sometimes due to the development of a 
neuritis affecting certain branches of the sacral plexus, while in other 
cases pressure exerted by an inflammatory exudate is responsible. I 
have seen a case of the latter character, which had persisted for years 
in spite of continuous treatment, disappear as if by magic after laparot¬ 
omy and the separation of the adherent appendages from the posterior 
and lateral portions of the pelvic wall. 

Winschied has directed particular attention to the rare cases of 
neuritis which follow delivery. The condition may be general or local¬ 
ized. In the latter only one or two nerves are affected—the median, 
ulnar, or crural—and atrophic symptoms soon make their appearance. 
In the former, since a number of nerves are implicated simultaneously, 
sometimes even those of the face not escaping, the symptoms may be 
manifold and the condition become most serious. In either event we 
are ignorant concerning the mode of production of the nerve lesions, 
although when generalized they are supposed to be due to toxemic in¬ 
fluences, being occasionally noted after toxemic vomiting and other 
toxic conditions. The prognosis is fair'for the localized but poor for 
the generalized variety, although even the latter occasionally undergo 
spontaneous cure. 

It is also important to bear in mind that separation of the symphysis 
pubis, or of one or other sacro-iliac synchondrosis during labor, may be 
followed by pain, and by so marked an interference with locomotion as at 
first sight to suggest the existence of paralysis. Moreover, the disturb¬ 
ances in the function of the psoas muscles and the adductors of the 
thigh, which so frequently accompany the early stages of osteomalacia, 
might readily lead to a similar error. 

In addition to these more localized processes the puerperal woman 
may occasionally suffer from paralysis of central origin. In most in¬ 
stances these result from various varieties of apoplexy, and occasionally 












OBSTETRICAL PARALYSES 


1033 


from areas of ceiebral degeneration incident to eclampsia and the other 
toxemias. 

As a result of a difficult labor, and exceptionally after an easy one, 
the child is sometimes born presenting an affection of the arm which is 
pommonly know n as Duchcnne s paralysis. In this form, paralysis of 
the deltoid, infiaspinatus, and the flexor muscles of the forearm causes 
the entile arm to fall close to the side of the body, and at the same 
time to rotate inward, while the forearm becomes extended upon the 
arm. The motility of the fingers is usually retained. 

Erb pointed out that such a paralysis could be due only to a lesion 
involving the fifth and sixth roots of the brachial plexus, and showed 
that electrical stimulation at a point from 2 to 3 centimeters above 
the clavicle and in front of the transverse process of the sixth cervical 
vertebra—now known as Erb’s point—produces contractions of the mus¬ 
cles involved. He considered that the paralysis frequently follows com¬ 
pression of the plexus by the clavicle in the Prague method of extraction 
more particularly when the arms have become extended over the head. 
In other cases its production is attributed to traction with the fingers 
in the axilla of the child, and occasionally to the use of forceps. 

That compression may be exerted during the employment of either 
of the first two of these maneuvers is at once evident from a consideration 
of the anatomical relations. On the other hand, the experiments of 
Stolper show that the plexus cannot possibty be compressed by the tips 
of the forceps so long as the child presents by the vertex, although it 
may occur in face or brow presentations. 

Carter, in 1893, was the first to direct attention to the fact that the 
condition is due to stretching of the upper roots of the brachial plexus 
more frequently than to abnormal pressure. His results were confirmed 
by the experimental work of Fieux, Schumaker, and Stolper, all of whom 
demonstrated that the plexus was readily subjected to extreme tension as 
a result of pulling obliquely upon the head, thus sharply flexing it toward 
one or other shoulder. As traction in this direction is frequently em¬ 
ployed in order to effect delivery of the shoulders in vertex presentations, 
it is readily seen that Euchenne’s paralysis may follow comparatively 
simple or even spontaneous labors. In view of these considerations, 
therefore, in extracting the shoulders care should be taken not to bring 
about too great lateral flexion of the neck. Moreover, in breech extrac¬ 
tions the Prague maneuver should be employed only when absolutely 
necessary, and particular attention should be devoted to preventing the 
extension of the arms over the head, as it not only materially complicates 
delivery, but adds considerably to the danger of infantile paralysis. 

The prognosis is usually fair, many of the children recovering. Occa¬ 
sionally, however, a case may resist all treatment and the arm may 
remain hopelessly paralyzed. All of the instances which I have person¬ 
ally observed ended in recovery, but in some of them prolonged treatment 
was necessary. In this form of paralysis the child should be promptly 
put under the care of a competent orthopedic surgeon, as the intelligent 
use of postural treatment will insure a useful arm, even if degenerative 
changes occur in the nerves and muscles. 






1034 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 

Abnormalities and Diseases of the Breasts.—Complete absence of 
both breasts is one of the rarest anomalies of development, while the 
absence of one and the normal development of the other breast have 
been noted in a few isolated cases. 

Hypertrophy of the breasts is more often observed, but abnormal 
enlargement is nevertheless an infrequent occurrence. In a large pro¬ 
portion of the recorded cases the condition developed rapidly in young 
unmarried women, both breasts being implicated and occasionally attain¬ 
ing such immense proportions that amputation became necessary. Cases 
have been reported in which a single breast weighed more than 50 
pounds. The hypertrophy sometimes recedes during lactation, so that 
the abnormality does not always afford an absolute contra-indication to 
suckling the child. Overdevelopment of the mammae is sometimes ob¬ 
served in men, a number of cases having been collected by Laurent. 

Supernumerary Breasts. —Probably one in every few hundred women 
has one or more accessory breasts— polymastia. Reference to 262 such 
cases are to be found in Goldberger’s article. 

The supernumerary breasts are sometimes so minute as to be mistaken 
for small pigmented moles, and rarely attain any considerable size. They 
are often provided with distinct nipples, and are most commonly situated 
upon the anterior thoracic or abdominal walls, usually near the mammary 
line; less frequently they are found in the axillae, and occasionally 
upon other portions of the body—the shoulder, flank, or groin, and in 
rare instances the thigh. These supernumerary breasts vary greatly in 
number, Neugebauer having described a patient with ten. 

The condition is usually regarded as an atavistic reversion, though 
it is not associated with an increased tendency toward multiple pregnancy. 
In not a few instances an apparent hereditary influence can be traced. 
Not all observers, however, accept this view, Ahlfeld holding that the 
distribution of the mammary tissue is to be attributed to the transference 
at an early period of development by means of the amnion of some of 
the cells, which ordinarily go to form the breasts, to other portions 
of the body. The condition has no obstetrical significance, though occa¬ 
sionally the enlargement of supernumerary breasts occupying the axillae 
may result in considerable discomfort to the patient. Quite frequently 
a tongue of mammary tissue may extend out into the axilla from the 
outer margin of a normal breast, while sometimes an isolated fragment 
will be found in the same location. Such structures undergo hyper¬ 
trophy during pregnancy, and when lactation is being established become 
swollen and painful. Ordinarily, if let alone, they soon undergo regres¬ 
sion and give no further trouble. 

Abnormalities of the Nipples. —The typical nipple is cylindrical in 
shape and projects well beyond the general surface of the breast, its 
exterior being slightly nodular but free from fissures. Variations from 
the normal, however, are not uncommon, some of them being so pro¬ 
nounced as to interfere seriously with the act of suckling. 

In some women the lactiferous ducts open directly into an area which 
forms a depression at the center of the areola. In pronounced instances 
of this so-called depressed nipple nursing is out of the question, although 


ABNORMALITIES AND DISEASES OF THE BREASTS 


1035 


when the depression is not very deep the breast may occasionally be 
made available by the employment of a nipple-shield. 

More frequently, although not depressed, the nipple is so stunted that 
it hardly projects above the surface of the breast, and in consequence 
can be seized by the child’s mouth only with the greatest difficultv. In 
the presence of this anomaly daily attempts should be made during the 
last few months of pregnancy to draw the nipple out by traction with 
the fingers, and a wooden nipple-shield should be constantly worn in 
the hope that by exerting pressure upon the periphery of the areola the 
nipple itself may be gradually made to protrude through the opening 
of the shield. 


Again, it sometimes happens that nipples which are normal in shape 
and size may present so fissured or nodular a surface as to be especially 
susceptible to injury from the child’s mouth during the act of suckling. 
In such cases small cracks or fissures almost inevitably appear, and render 
nursing so painful that the mother dreads the approach of the child, and 
the mental distress so induced often has a deleterious influence upon the 
secretory function. Moreover, such lesions are still more serious in that 
they offer a convenient portal of entry for pyogenic bacteria which are 
liable to invade the breast and give rise to a mastitis. 

Abnormalities in the Mammary Secretion. —Marked individual varia¬ 
tions exist in the amount of milk secreted, many of which are dependent 
not upon the general health and appearance of the individual, but upon 
the degree of development of the glandular portions of the breasts. Thus 
we often find that a woman who possesses large, well-formed breasts, and 
who apparently should be an excellent milk-producer, secrets only a small 
quantity; while, on the other hand, one is often surprised at the abun¬ 
dant supply produced by another whose mammae are small and flat. It is 
a matter of common observation that stout women with redundant 
breasts usually have a very deficient secretion, the bulk of the organ 
being made up of fatty tissue while the glandular elements are poorly 
developed. Deficient secretion is likewise frequently noted in very young 
women and in elderly primiparae. In the former the defect is to be 
attributed to imperfect development; in the latter to regressive and 
atrophic changes in the breasts. 

In very rare instances there is an absolute lack of mammary secre¬ 
tion— agalacia. As a rule, however, the defect is not absolute, as it is 
nearly always possible to cause at least a small amount to exude from 
the nipple on the third or fourth day of the puerperium. On the other 
hand, relative deficiency is frequently observed, a large number of women 
secreting an amount of milk quite insufficient for the nutrition of the 
child. In Chapter XVII reference was made to the variations in the 
quantity of the milk as well as the various factors which may be con¬ 
cerned in their production. 

Occasionally the mammary secretion is excessive— polygalacia —and 
may even be so abundant that milk is constantly escaping from the 
nipples. This latter condition, which is known as galactorrhea, some¬ 
times continues for years after the birth of the child, and is extremely 
intractable to treatment. Nothing is known as to its cause. Although 




1036 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


in rare instances the health of the woman may remain unimpaired, as 
a rule she soon begins to show evidences of the continuous drain upon 
her system, becoming irritable, querulous, and eventually developing 
symptoms of cachexia. 

Galactorrhea is best treated by not attempting to empty the breast, 
but by allowing it to become engorged, in the hope that the intramam¬ 
mary pressure will become so great as to compress the vessels and thus 
check secretion. At the same time the breasts should be supported by a 
bandage, and fairly large doses of potassium iodid should be admin¬ 
istered. Good effects are also said to have been obtained from the use 
of chloral. In a certain number of cases the condition is combined 
with atrophy of the uterus, and several observers have reported improve¬ 
ment following procedures which tend to bring about an increase in 
size of the uterus, such as the use of the vaginal douche, local applications 
to the cervix, or the employment of electricity. 

Diseases of the Nipples. —The mode of production and treatment of 
fissures of the nipples has already been considered in detail in Chapter 
XVII. 

Engorgement of the Breasts. —For the first tw r enty-four or forty- 
eight hours following the development of the lacteal secretion, it is not 
unusual for the breasts to become immensely distended, and to offer on 
palpation a firm, nodular resistance. This condition, which is commonly 
known as “caked breast,” often gives rise to a considerable degree of 
pain, and is sometimes accompanied by a slight elevation of temperature. 
Within a day or so the engorgement usually passes off spontaneously, 
or as the result of appropriate treatment, though in some cases it persists 
in spite of all that can be done, and may be a forerunner of the develop¬ 
ment of a mammary abscess. It is probable that the excessive distention 
of the glandular portion of the breast leads to slight tissue changes, 
thereby offering a locus minoris resistentiae for invasion by bacteria, 
which are usually present in the lactiferous ducts. 

Whenever the breast becomes markedly engorged immediate steps 
should be taken to relieve the condition. This is most readily accom¬ 
plished by drawing the breasts firmly against the thorax by means of a 
tight binder, applying an ice bag, and if necessary giving % grain of 
codeia, which may be repeated in three hours if necessary. Usually this 
will relieve the condition within twenty-four hours, and the physician 
is cautioned not to be too hasty in resorting to other measures. 

If the engorgement does not show signs of subsiding within this 
period, and particularly when the child is unable to draw off a sufficient 
quantity of milk, an English breast-pump should be employed to remove 
the excess. Sometimes this procedure proves ineffectual, and relief can 
be obtained only by massage. The nurse having anointed the palmar 
surfaces of her hand with olive-oil, mixed with equal parts of laudanum 
if the breasts are very sensitive, makes stroking movements, beginning 
at the periphery of the breast and gradually approaching the nipple. At 
first the manipulations should be made very gently, but as the patient 
becomes accustomed to them more force may be employed, which will 
soon cause the milk to exude from the nipple. After the breast has 


ABNORMALITIES AND DISEASES OF THE BREASTS 


1037 


been emptied the bandage should be reapplied, as it not only relieves pain 
by preventing the overloaded organ from sagging downward, but at 
the same time serves to diminish the amount of secretion by diminishing 
the blood supply. That the engorgement is usually transient and the 
use of special treatment is unnecessary is clearly shown by the fact 
that I have not employed massage or the breast pump for years. In 
many instances I believe that the use of these measures often defeats 
the very purpose for which they are employed, as they stimulate rather 
than diminish the secretory activity of the breasts. 

Drying up the Breasts .—After the death of the child, or in cases in 
which for one reason or another the continuance of lactation is thought 
inadvisable, steps must be taken for checking the lacteal secretion, or 
“drying up the milk,” as it is usually designated. Formerly this was 
accomplished by the use of the binder, the application of belladonna 
ointment, and the employment of the breast-pump and massage when 
the engorgement became pronounced. The process was frequently very 
painful to the patient, very troublesome to the nurse, and usually had 
to be employed for a week or ten days or even longer before the desired 
result was obtained. 

In 1904 Dr. E. R. Lewis, of Westerly, R. I., told me that much more 
satisfactory results could be obtained by the administration of 20 grains 
of potassium acetate every six hours. I immediately put his suggestion 
into practice, and found that the breasts dried up in the course of two 
to four days without other treatment. Further investigations, however, 
showed that the potassium acetate was of no value, as equally satisfactory 
results followed if drugs were not used. 

Accordingly, when it is desired to “dry up” the breasts, they are left 
absolutely alone. In the course of twenty-four hours they become more 
or less engorged, and sometimes very painful. If the pain is severe, % 
grain of codeia is administered, and repeated if necessary, but the breast- 
pump or massage is not employed. Within a few hours the engorgement 
begins to subside spontaneously and the amount of secretion to decrease, 
so that by the end of another twenty-four hours the breasts become soft 
and painless. With each succeeding day the secretion becomes less and 
less abundant, and practically disappears in the course of a week. 

H. J. Storrs, in 1909, published a report of the cases so treated 
in our clinic, and stated that not a single breast abscess had developed 
during the period of observation, and that less than one woman in 
ten complained of sufficient pain to necessitate the administration of a 
sedative. I have employed this method exclusively since 1915, and since 
then I have had no occasion to employ belladonna ointment, the breast- 
pump, massage, or the tight breast binder. Ice bags, however, are used, 
and when the breasts are large and pendulous they are supported by 
means of a binder, which does not exert pressure upon them. 

Inflammation of the Breasts — Mastitis .—Parenchymatous inflamma¬ 
tion of the mammary glands is a rare complication of pregnancy, but 
is frequently observed during the puerperium and lactational period. 
Whitcher in 1914 collected a number of cases of the former complication, 
and showed that it did not differ from the puerperal type except in the 



1038 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


time of its appearance. The symptoms of mastitis rarely appear before 
the end of the first week of the puerperium, and as a rule not until 
considerably later. Marked engorgement usually precedes the inflamma¬ 
tory trouble, the first sign of which is afforded by chilly sensations or 
an actual rigor, which is soon followed by a considerable rise in tempera¬ 
ture and an increase in the rate of the pulse. The breast becomes hard, 
its surface is reddened, and the patient complains of acute pain. In 
many instances, by the end of twenty-four hours the condition disappears 
spontaneously without treatment, being often favorably influenced by 
the application of cold and of a tightly fitting bandage. But if the 
symptoms persist for longer than forty-eight hours, suppuration is to 
be expected. The process may remain limited to a single lobe if the 
abscess is opened promptly; but if left to itself the breast is liable to 
become undermined in all directions, and, as a result, the destruction 
of tissue is extensive, and the external surface may be left riddled with 
numerous fistulous tracts. 

In some cases the constitutional symptoms attending a mammary 
abscess are very pronounced, and very exceptionally lead to a fatal termi¬ 
nation. On the other hand, the local manifestations may be so slight as 
to escape observation. Such cases are usually mistaken for puerperal 
infection, and give rise to no little anxiety until the examination of 
cultures from the uterine cavity has demonstrated the absence of bac¬ 
teria. In still another group of patients the process pursues a subacute 
or almost chronic course, the breast being somewhat harder than usual 
and more or less painful, but constitutional symptoms are either lacking 
or very slight. Under such circumstances the first indication of the 
true state of affairs is often afforded by the detection of fluctuation. 

Etiology .—Mastitis is always the result of infection, pathogenic bac¬ 
teria from outside gaining access to the breast through fissured nipples 
by way of the lymphatics; or else some of those already present in the 
lactiferous ducts meet with conditions which enable them to invade the 
tissues. The researches of Bumm, Hbnigmann, Koestlin, and others have 
demonstrated that Staphylococcus albus is present in 80 to 94 per cent, 
of all breasts. Ordinarily this microorganism lives in the milk as a 
harmless parasite, but when the tissues are seriously altered as the 
result of engorgement, it is possible for it to become pathogenic. Rubeska 
reported the following bacteriological findings in 16 cases of mammary 
abscess: 


Staphylococcus aureus. 9 cases 

Staphylococcus aureus and albus. 3 11 

Staphylococcus albus. 3 “ 

Streptococcus. 1 case 


Exceptionally, other bacteria are causative agents, Sarfert having demon¬ 
strated the gonococcus, Chassot the bacillus pvocyaneus, and Little the 
gas bacillus. 

When the infection occurs through fissured nipples the inflammation 
is usually phlegmonous in character. In some cases it involves only the 
connective tissue beneath the breast, a large collection of pus being 
formed between it and the thoracic wall—retromammary abscess. Again, 






ABNORMALITIES AND DISEASES OF THE BREASTS 1039 

the infection may be limited to the areola, beneath which small abscesses, 
rarely exceeding 1.5 centimeters in diameter, may develop —subareolar 
mastitis. In rare instances the affection may be erysipelatous in charac¬ 
ter, and be limited to the superficial tissues. 

According to Winckel, 67.6 per cent, of all cases of mastitis occur in 
primiparae, but its actual incidence varies according to the care given 
the patients during pregnancy and the puerperium. Thus, the statistics 
of Rubeska show a frequency of 0.54 to 4.1 per cent, in the various Ger¬ 
man clinics. Generally speaking, it may be said that the frequent occur¬ 
rence of mastitis is indicative of neglect on the part of the physician or 
nurse. 

Treatment .—The occurrence of mastitis can be prevented in great 
part by suitable prophylactic measures, which mainly consist in prevent¬ 
ing the development of fissured nipples or treating them properly after 
they have appeared. 

The most suitable measures for treating the nipples during preg¬ 
nancy, so as to enable them to better withstand the strain of nursing, 
have already been mentioned in Chapter XVII. When lactation becomes 
established the strictest cleanliness should be observed and the nipples 
w r atched most carefully. As soon as a fissure begins to develop a nipple- 
shield should be employed, the child not being allowed to apply the 
mouth directly to the. nipple until healing has taken place. In the 
intervals between the feedings the sore nipple should be covered with a 
piece of absorbent cotton soaked in a saturated solution of boric acid. 
The various applications which are usually recommended, however good 
in themselves, will prove practically valueless, unless the nipple can be 
placed at comparative rest, which is best afforded by the use of a suitable 
nipple-shield. If the condition becomes worse after some days’ trial of 
this treatment it is advisable to wean the child rather than take the risk 
of infection, which is so prone to follow if the deeply fissured nipple be 
used for any length of time. 

On the first symptom of mammary infection the breast should be 
put at rest as far as possible by not allowing the child to nurse it, and 
withdrawing the milk, if necessary, by means of a breast-pump. After 
being emptied the breast should be thickly covered with cotton, and by 
means of a tightly fitting bandage subjected to the greatest possible 
pressure consistent with the comfort of the patient, and an ice bag 
applied. In many cases such treatment apparently cuts short the 
process, the symptoms disappearing within twenty-four hours, after which 
the patient is able to resume suckling her child. Usually, however, the 
process sooner or later eventuates in abscess formation. 

In early cases Bier reported excellent results following the use of his 
method of artificial hyperemia, but in my service the procedure has been 
of little value. As soon as definite evidence of fluctuation can be obtained 
the breast should be incised. Procrastination is not permissible, delay 
being synonymous with extension of the process, which frequently leads 
to such extensive destruction of tissue as to destroy permanently the 
physiological function of the organ. The incision should be made radi¬ 
ally, extending from near the areolar margin toward the periphery of the 








1040 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


gland, in order to avoid injury to the lactiferous ducts. In early cases a 
single incision over the most dependent portion of the area of fluctuation 
is usually sufficient, but when multiple abscesses are present several in¬ 
cisions may be required. The operation should always be done under 
anesthesia, and should not be considered as completed until the obstetri¬ 
cian has introduced a finger through the incision and carefully explored 
the interior of the breast, breaking down the partition walls between the 
various pockets of pus, so that only a single abscess cavity is left to be 
dealt wuth. This should then be loosely packed with gauze, and re¬ 
placed at the end of twenty-four hours by a smaller pack. If the pus 
has been thoroughly evacuated, the abscess cavity becomes obliterated 
with a rapidity which is sometimes surprising. 

Galactocele .—Very exceptionally, as the result of the clogging of a 
milk duct by inspissated secretion, an accumulation of milk may take 
place in one or more lobes of the breast. Ordinarily this is limited in 
amount, but may become excessive and form a fluctuant tumor which 
may give rise to pressure symptoms. In many instances massage and the 
application of a tight bandage will cause it to disappear, and I have 
never seen the structure attain such size that puncture became imperative. 

Puerperal Psychoses.—Reference has already been made to the altera¬ 
tions in the mental condition which may accompany pregnancy. These 
vary from slight changes in disposition to actual insanity, though for¬ 
tunately the latter is of relatively rare occurrence. 

In the absence of the usual etiological factors or an hereditary taint, 
the insanity of pregnancy is usually a manifestation of auto-intoxication, 
and may be accompanied by melancholic or maniacal symptoms. It 
usually persists throughout the remainder of gestation, but disappears 
shortly after labor. 

Puerperal insanity, on the other hand, is more common, and accord¬ 
ing to the statistics compiled by Berkley and Jones is noted once in 
every 616 and 1,100 labors, respectively. In former times it was a com¬ 
paratively common complication, and it would seem that the introduction 
of aseptic methods into obstetrics is responsible for a reduction by one 
half in its incidence. The affection usually makes its appearance within 
the first two weeks following delivery. When it occurs later it is desig¬ 
nated as lactational insanity. 

Puerperal psychoses may be due to one of three causes: infection, 
auto-intoxication, or direct lability of the nervous system. Of these, 
the former is by far the most important. This fact has long been recog¬ 
nized, but it is only of late that the bacteria concerned have been identi- 
field, and then only in a small proportion of the cases. In two instances 
which have come under my observation the infection was due to strep¬ 
tococcus, while in a third, it was due to the streptococcus and colon 
bacillus. 

Auto-intoxication is also a frequent etiological factor. According to 
Hansen and Picque, infection and auto-intoxication are responsible for 
more than 80 per cent, of all cases, while the remainder are to be 
attributed to other causes, and occur particularly in women afflicted with 
hereditary tendencies, the exciting cause of the insanity being shock. 


MALARIAL FEVER 


1041 


extreme mental depression, or the rapid loss of a large quantity of blood. 

i sychical disturbance is a well recognized, but fortunately rare, com¬ 
plication of eclampsia, usually appearing several days after the cessation 
ot convulsions. In my experience it occurs about once in forty or fifty 

cases, though Olshausen observed it in 6 per cent, of his 515 eclamptic 
cases. 

The pueipeial psychoses are usually characterized by great excite¬ 
ment during the first few days, associated with all sorts of hallucinations. 
Latei the maniacal symptoms disappear, and the patient passes into a 
condition of depression, and frequently exhibits suicidal tendencies. 

The piognosis is most favorable in the cases following eclampsia, the 
majority of such patients recovering within a few weeks. On the other 
hand, those following infection are very tedious, and 20 to 40 per cent, 
of the v omen fail to regain their mental equilibrium. It is not unusual 
for the disturbance to last for from three to six months, although the 
prospect for recovery is poor if the latter period is exceeded. It is 
generally stated that from 5 to 10 per cent, of the patients afflicted with 
puerperal insanity die, this high mortality rate being due, of course, to 
the underlying infection and not to the mental derangement itself. 

In cases following infection the treatment should first be directed to 
the underlying condition, and the directions described in Chapter XLIII 
rigorously followed. The acute maniacal symptoms should be met by 
the administration of sedatives, and the patient should be watched most 
carefully throughout her entire illness, more particularly during the 
periods of depression, during which she should never be left alone for 
fear that she may do an injury to herself. If prompt improvement does 
not follow the disappearance of the symptoms ascribable to infection, 
the patient should be placed in charge of a competent psychiatrist. 

Typhoid Fever.—This is not an infrequent complication of the puer- 
perium. Its course, however, varies but little from that observed under 
other conditions, although the prognosis is necessarily somewhat in¬ 
fluenced by the fact that the patient is already debilitated by the strain 
incident to labor. The diagnosis should never be made unless a definite 
Widal reaction can be demonstrated, inasmuch as all the other symptoms 
of the disease may be associated with a prolonged puerperal infection, 
especially when the endocardium is involved. Furthermore, the so-called 
typhoid condition is often encountered in various forms of pyemia. 

Malarial Fever.—In certain districts the puerperium is sometimes 
complicated by malarial infection. Although the course of the disease 
is not materially influenced by the fact that the patient has recently 
given birth to a child, it is interesting to note that labor, no less than 
surgical procedures, seems to predispose to a recrudescence of the dis¬ 
order in women who have already suffered from it, the typical phe¬ 
nomena often appearing during the first few days of the puerperium. 

Too many sins of omission and commission on the part of the obste¬ 
trician have undoubtedly been cloaked under the diagnosis of “malaria.” 
At the present day, whenever a puerperal patient presents a temperature 
characterized by marked remissions and possibly by chills, puerperal in¬ 
fection should be suspected, and the existence of malarial fever should not 


1042 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


be seriously entertained unless all other possibilities have been practically 
eliminated and the characteristic parasites have been found in the 
blood. 

As soon as a positive diagnosis has been made, quinin should be 
given in sufficiently large doses to break up the attack, as the drug exerts 
no appreciable influence upon the mammary secretion or the well-being 
of the child. 

Pneumonia .—Croupous pneumonia is a rare complication of the 
puerperal state, unless the disease has existed before the onset of labor. 
The outlook is always serious. 

The lobular variety, or bronchopneumonia, is often a terminal process, 
and is one of the most common causes of death in patients who succumb 
within a few days following an eclamptic attack. The treatment does 
not differ essentially from that employed at other times. 

Scarlet Fever.—Although scarlet fever is rarely encountered during 
the puerperium, its occurrence has given rise to a great deal of dis¬ 
cussion and a very considerable literature. The interest manifested 
in the disease is largely to be accounted for by the fact that a scarlatini- 
form rash is occasionally observed during the course of a puerperal in¬ 
fection, so that in many cases a differential diagnosis becomes very 
difficult. 

Epidemics of scarlet fever in the puerperium have been reported by 
Boxall, Meyer, Ahfeld, and others. Nevertheless, it would appear that 
the puerperal woman is to a certain extent immune from the disease, 
inasmuch as statistics go to show that only a small proportion of those 
exposed to the contagion become infected. Thus, Meyer found the rate 
of morbidity to be about 1 per cent, among his patients. 

It is generally stated that infection may occur in the usual manner, 
as well as by the entrance of the specific poison through wounds about 
the genitalia. The belief in the possibility of the latter eventuality is 
based upon the fact that the rash occasionally appears first in the neigh¬ 
borhood of the vulva, and ihence spreads to other portions of the body. 
Moreover, the frequent association of pelvic inflammatory troubles, and 
the occasional localization of diphtheritic patches in the vulva or vagina, 
instead of in the throat, are advanced in support of the view. Modern 
bacteriological investigation, however, has destroyed the force of this 
last agrument, since it has shown that the so-called diphtheritic deposits 
occurring in the throat in scarlet fever are due to a coincident strep¬ 
tococcic infection. Moreover, since such conditions about the genitalia 
usually ha’v e a similar origin, it would appear difficult to differentiate 
betw een those complicating scarlet fever and the varieties occurring dur¬ 
ing the course of puerperal infection. It is also urged that the appear¬ 
ance of the disease on the third or fourth day of the puerperium speaks 
in favor of transmission of contagion through the genitalia. 

In frank cases the diagnosis is readily made from the existence of a 
characteristic rash, which is later followed by desquamation. Moreover, 
the strawberry tongue, the development of pseudodiphtheritic patches 
m the pharynx, the appearance of albumin in the urine, together with 
a history of exposure to possible contagion, usually remove all doubt. On 


LITERATURE 


1043 


the other hand, in the absence of characteristic manifestations, the 
diagnosis cannot be made, it being often impossible to differentiate be¬ 
tween scarlet fever and puerperal infection, even when a distinct history 
of exposure to contagion can be elicited. 

The prognosis is largely the same as under other circumstances, mild 
forms, as a rule, ending in recovery, whereas patients affected with the 
hemorrhagic variety usually die. The puerperium appears to exert little 
effect upon the course of the disease, the death-rate not being higher 
than under ordinary conditions. The child may or may not be infected. 

Measles and smallpox occasionally occur during the puerperium, but 
their course does not differ materially from that observed in women who 
have not recently given birth to children. 

Diphtheria.—True diphtheritic patches, in which the Klebs-Loeffler 
bacillus can be demonstrated, occasionally occur upon denuded portions 
of the vulva and vagina. They may be due to a primary genital infec¬ 
tion, or be merely part of a process primarily localized in the throat. 
Such lesions, however, should be more frequently observed if the 
observations of Wauschkuhn are correct; as he stated that the vaginal 
secretion frequently harbors diphtheria bacilli; which he was able to 
isolate from eleven of a series of 200 women. Inasmuch as pseudodiph- 
theritic patches in the genital tract during the course of puerperal in¬ 
fection are of frequent occurrence, the presence of fibrinous exudates 
about the vagina or vulva should lead to a diagnosis of diphtheria only 
when the characteristic bacilli can be demonstrated. If the process is 
limited to the genital tract, the constitutional symptoms are not severe, 
and the disease usually pursues a benign course, readily yielding to the 
employment of antidiphtheritic serum. 


LITERATURE 

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des Menschen. Leipzig, 1880, 110-113. 

Ueber Exantheme im Wochenbette, etc. Zeitschr. f. (leb. u. Gyn., 1893, xxv, 
31-44. 

Berkley. The Insanities of the Puerperal Period. A Treatise on Mental Dis¬ 
eases, 1900, 307-328. 

Boxall. Scarlatina during Pregnancy and in the Puerperal State. Trans. Lond. 
Obst. Soc., 1889, xxx, 11-77; 126-154. 

Bumm. Zur Aetiologie der puerperalen Mastitis. Archiv f. Gyn., 1886, xxvii, 
460-484. 

Burckhard. Gangran der unteren Extremitaten im W ochenbette. Zentralbl. f. 
Gyn., 1900, xxiv, 1381-1384. 

Carter. Obstetrical Paralysis, etc. Boston Med. and Surg. Jour., May 4, 1893. 
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1889, No. 74. 

Qjjjari, Braun, und Spaeth. Acquirirte "V olumsabnahme des Uteiuskorpers. 
Klinik der Geb., 1854, 371-372. 

Deneux. Memoire sur les tumeurs sanguines de la vulve et du \agin. Paris, 
1830. 


1044 DISEASES AND ABNORMALITIES OF THE PUERPERIUM 


Doderlein. Die Atrophia uteri. Veit’s Handbuch der Gyn., 1897, ii, 391-402. 

Duchenne* Paralysies obstetricales infantiles du membre superieur. De 1’elec¬ 
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Feeux. De la pathogenie des paralysies brachiales chez le nouveau-ne. Annales 
de gyn. et d'obst., 1897, xlvii, 52-64. 

Goldberger. Ein seltener Fall von Polymastie. Archiv f. Gyn., 1895, xlix, 272- 
277. 

Gottschalk. Beitrag zur Lehre von der Atrophia uteri. Volkmann s Sammlung 
klin. Vortrage, N. F., Nr. 49. 

Hansen. Ueber das Verhaltniss zwischen der puerperalen Geisteskrankheit u. der 
puerperalen Infection. Zeitschr. f. Geb. u. Gyn., 1888, xv, 60-127. 

Heyse. Ueber Tetanus puerperalis. Deutsche med. Woclienschr., 1893, Nr. 14, 
318. 

Honigmann. Bakteriologische Untersuchungen iiber Frauenmilch. D. I., Breslau, 
1893. 

Hosslin. Ueber periphere Schwangerschaftslahmungen. Munchener med. Woch¬ 
enschr., 1905, Nr. 14. 

Howland and Kichards. An Experimental Study of the Metabolism and 
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344-72. 

Hunermann. Ueber Nervenlahinung im Gebiete des Nervus ischiadicus infolge 
von Entbindungen. Archiv f. Gyn., 1900, xlii, 489-512. 

Jacquet. Ueber Atrophia uteri. Berliner Beitrage zur Geb. u. Gyn., 1873, ii, 
1 - 11 . 

Jones. Puerperal Insanity. Jour. Obst. and Gyn Brit. Emp., 1906, iii, 109-125. 

Kostlin. Beitrage zur Frage des Keimgehaltes der Frauenmilch u. zur Aetiologie 
der Mastitis. Archiv f. Gyn., 1897, liii, 201-277. 

Kunzig. Ueber das Haematom der Vulva und der Vagina. D. I., Tubingen, 1895. 

Lafond. De la gangrene des membres inferieurs dans les suites de couches. 
These de Bordeaux, 1901. 

Laurent. Gynakomastie, etc. Bibliothek fur Socialwissensehaft. Leipzig, 1896, 
vi. 

Lynch. Retroversions of the Uterus following Delivery. Trans. Am. Gyn. Soc., 
1922, xlvii, 177-192. 

Meyer. Ueber Scharlach bei Wbchnerinnen. Zeitschr. f. Geb. u. Gvn., 1888, xiv, 
289-351. 

Neugebauer. Eine bisher einzig dastehende Beobachtung von Polymastie mit 10 
Brustwarzen. Zentralbl. f. Gyn., 1886, x, 729-736. 

Olshausen, Beitrag zu den puerperalen Psychosen, speciell den nach Eklampsie 
auftretenden. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 371-385. 

PiCQUfi. Considerations sur les psychoses post partum. Bull, de la soc. d ’obst. 
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Rubeska. Beitrage zum Tetanus puerperalis. Archiv f. Gyn., 1897, liv, 1-12. 

Zur Behandlung von wunden Warzen und Mastitiden im V T ochenbett. Archiv 
f. Gyn., 1899, lviii, 177-184. 

Sarfert. Diplokokken im Eiter bei Mastitis. Deutsche med. W’ochenschr., 1894, 
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Schumaker. I eber die Aetiologie der Entbindungslahmungen, etc. Zeitschr. f. 
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Schwarz. The Pathology of Chronic Metritis and Chronic Subinvolution. Am. 
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Smith. The Subinvoluted Uterus. Surg. Gyn. and Obst., 1910, x, 17-27. 

Spiegel. Zur Kenntniss des Tetanus puerperalis. Archiv f. Gyn. 1914. ciii, 
367-392. 


LITERATURE 


1045 


Stolper. Ueber Entbindungsliihmungen. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 
49-65. 

Storrs. Checking the Secretion of the Lactating Breast. Surg. Gyn. and Obst., 
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Thomas. Obstetrical Paralysis, Infantile and Maternal. Bulletin Johns Hopkins 
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Vortrage, 1910, Nr. 602 and 603. 

Vinay. Du tetanus puerperal. Archives de tocologie, 1892, xix, 179. 

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Wauschkuhn. Ueber das Vorkommen von echten Diphtheriebazillen bei Gebaren- 
den und Neugeborenen. Zentralbl. f. Gyn., 1920, 820-824. 

Whipple. Pregnancy and Chloroform Anasthesia. Jour. Exp. Med., 1912, xv, 
246-258. 

Whipple and Sperry. Chloroform Poisoning. Bull. Johns Hopkins Hospital, 
1909, xx, 278-289. 

Whitcher. Mastitis in Pregnancy. Boston Med. & Surg. Jour., 1914, clxxi, 
970-973. 

Williams. Subperitoneal Hiematoma following Labour, not associated with 
Lesions of the Uterus. Trans. Am. Gyn. Soc., 1904, xxix, 186-205. 

Winckel. Entziindung des Brustdriisenparenchyms, etc. Die Pathologie u. 
Therapie des Wochenbetts. III. Aufl., 1878, 428-439. 

Winscheid. Neuritis gravidarum und Neuritis puerperalis. Graefe’s Sammlung 
zwangloser Abhandlungen auf dem Gebeite der Frauenheilkunde und Geb., 
1898, iii, Heft 8. 

Wormser. Nochmals zur puerperalen Gangran der unteren Extremitaten. Zen¬ 
tralbl. f. Gyn., 1901, xxv, 110-112. 

Ueber puerp. Gangran der Extremitaten. Wiener klin. Rundschau, 1904, Nr. 
5 u. 6. 







INDEX 


Abderhalden’s reaction, 213. 

Abdomen, discoloration of, in pregnancy, 
190. 

enlargement of, during pregnancy, 210. 
foetal, enlarged, cause of dystocia, 900. 
pendulous, 220, 847. 
striae of, in pregnancy, 190. 

Abdominal binder, 381. 
pedicle, 123, 125, 131. 
pregnancy, 738, 741. 

wall, changes in, during pregnancy, 190, 
570. 

during puerperium, 376, 381. 
emphysema of, 960. 
function of, during labor, 259, 277. 
Abortion, 701. 

changes in foetus in, 706. 
clinical history of, 708. 
complete, 709. 
criminal, 420, 701. 
curettage in, 421, 712. 
epidemic, 705. 
etiology of, 702. 
frequency of, 701. 
imminent, 709. 

in retroflexed pregnant uterus, 420, 646. 
in typhoid fever, 547. 
incomplete, 709. 

induction of, for contracted pelves, 421. 
for diseases of ovum, 420. 
for malignant growths, 421. 
for ovarian tumors, 421. 
for pernicious vomiting of pregnancy, 
420. 

for renal insufficiency, 420. 
for retroflexed pregnant uterus, 420, 647. 
for tuberculosis, 422. 
for uterine hemorrhage, 421. 
for uterine myomata, 421. 
for vomiting of pregnancy, 587. 
methods of, 422. 
inevitable, 709. 
infectious, of cattle, 705. 
lithopedion in, 708. 
missed, 713. 

mole, formation of, in, 706. 
pathology of, 706. 
prophylaxis of, 709. 
repeated, 705. 
threatened, 709. 
treatment of, 709. 
tubal, 732. 


Abscess, in puerperal fever, 989. 
of Bartholin’s gland, 636. 
of breast, 1038. 
metastatic, 990. 
pelvic, 989. 
retromammary, 1038. 

Acanthopelys, 898. 

Acardiacus, 407, 903. 

Accessory fontanel, 165. 

Accessory ostium of tube, 59. 

Accessory ovaries, 64. 

Accessory tubes, 60. 

Accidental hemorrhage, concealed, 922. 

Accidents during pregnancy, 570. 

Accommodation theory as to production of 
presentations, 240. 

Accouchement force, 431. 

for hemorrhage due to premature sep¬ 
aration of placenta, 926. 
in eclampsia, 624. 
in placenta previa, 937. 

Acephalicus, 903. 

Acetonuria during pregnancy, 201. 
during puerperium, 380. 

Achondroplasia, 826, 907. 

Acormus, 904. 

Acromio-iliac presentations. (See Trans¬ 
verse Presentations.) 

Acute infectious diseases in pregnancy, 545. 
edema of cervix, 649. 
yellow atrophy of liver, 587. 

Adherent placenta, 683. 

Adhesions, amniotic, 672. 

Adipocere, 740. 

Adrenal gland, in pregnancy, 196. 

Afterbirth, 147. 

After-coming head, forceps to, 467, 481. 
perforation of, 529. 

After-pains, 378. 

Agalacia, 1035. 

Age of foetus, calculation of, 160. 

Agglutination, in eclampsia, 611. 

Air, entrance of, into veins, 974. 

entrance of, into uterine sinuses, 974. 
infection, 993. 

Albuginea, 63. 

Albuminometer, Esbach’s, 595. 

Albuminuria, changes in the placenta in, 
679. 

Albuminuria during pregnancy, 194, 591, 
593. 

during puerperium, 379. 


10d7 



1048 


INDEX 


Albuminuria in eclampsia, 602. 
in labor, 379. 

relation to premature separation of pla¬ 
centa, 921. 

Albuminuric retinitis, 592. 

Allantois, 125. 

Amaurosis during pregnancy, 592, 602. 

Amenorrhea, conception during, 215. 

Ammonia coefficient, 584, 603. 

Amnesia, 363. 

Amnion, 111. 

adhesions of, 672. 
cysts of, 673. 
diseases of, 667. 
dropsy of, 667. 
fluid of, 133, 667. 
formation of, in bat, 116. 
in chicken, 111. 
in guinea pig, 115. 
in man, 114. 
in monkey, 116. 
inflammation of, 672. 
structure, 132. 

Amniotic adhesions, 672. 
caruncles, 132, 673. 
fluid, functions of, 173. 
origin of, 173. 

Amorphus, 903. 

Ampulla of tube, 56. 

Ampullar pregnancy, 726. 

Amputation, of leg, effect upon pelvis, 897. 
intra-uterine, 672. 

Anaerobic bacteria in puerperal infection, 
982. 

Anaphylaxis, 612. 

Anemia, pernicious, 568. 

Anencephalus, 904. 

Anesthesia, 359. 
in eclampsia, 624. 
in heart disease, 556. 
in irregular pains of first stage, 759. 
in normal labor, 359. 
in painful labor, 759. 

Aneurysm of foetus, 907. 

Annular detachment of cervix, 953. 

Anteflexion, in contracted pelves, 847. 
of pregnant uterus, 642. 
of puerperal uterus, 1029. 

Antepartum hemorrhage, 876. 

Anteversion of pregnant uterus, 642. 

Anthrax during pregnancy, 548. 

Antistreptococcic serum, 1014. 

Antitetanus serum, 1022. 

Anus, laceration of sphincter of, 367. 
lesions of, during labor, 260, 282. 

Apoplexy during pregnancy, 567. 
in eclampsia, 607. 
of placenta, 678. 
uteroplacental, 923. 

Appendicitis during pregnancy, 571. 

Apron, Hottentot, 28. 

Arbor vitse uterina, 41. 

Area, embryonic, 107. 
germinativa, 107. 
opaca, 107. 
pellucida, 107. 

Areola, of pregnancy, 191. 
secondary, 191. 


Armadillo, multiple pregnancy, in, 405. 

Arterial pressure, 192, 256. 

Arteries. (See Blood-vessels.) 

Artificial feeding, 400. 

respiration. (See Asphyxia.) 

Ascites, of foetus, obstructing labor, 906. 
simulating pregnancy, 220. 

Asphyxia, from rupture of vasa previa, 684. 
intra-uterine, 967. 
livida, 969. 
neonatorum, 967. 
pallida, 969. 
trepanation for, 970. 

Assimilation pelvis, 835. 

Asthma during pregnancy, 557. 

Atony of uterus, 413, 939. 

Atresia of cervix, 768. 
follicular, 188. 
of vagina, 767. 
of vulva, 766. 

Attitude of foetus, 234. 

Auscultation, obstetrical, 207, 245. 
errors in, 246. 
foetal heart, 207. 
foetal heart murmurs, 208. 
funic souffle, 208. 
gas in maternal intestines, 208. 
in multiple pregnancy, 411. 
movements of foetal diaphragm, 208. 
placental souffle, 208. 
uterine souffle, 208. 

Auto-infection, 993. 

Auto-intoxication, intestinal, 610, 629, 1005. 
relation of, to eclampsia, 610. 
to insanity, 1040. 

Autolysis in eclampsia, 614. 

Axis of pelvis, 10. 

Axis traction forceps, 464. 

Bacillus abortus, 705. 

aerogenes capsulatus, cause of emphysema 
of abdominal walls, 980. 
infection with, cause of foetal dystocia, 908. 
infection with, simulating air embolism, 
974. 

in puerperal infection, 980. 

Bacillus coli communis, in puerperal infec¬ 
tion, 980. 

in tympanites uteri, 980. 

Bacillus diphtheriae in puerperal infection, 
980. 

Bacillus typhosus in puerperal infection, 981. 

Bacterial orgin of eclampsia, 610. 

Bacteriology of lochia, 379, 1006. 
of puerperal infection, 977. 
of vaginal secretion, 995. 

Bag of waters, 258, 276, 352. 

Balloon, Champetier de Ribes, 430, 433. 

Ballottement, 209. 

Bandl’s ring. (See Contraction Ring.) 

Barnes’s fiddle-bag, 430. 

Bartholin’s glands, 30. 

inflammation of, during pregnancy, 636. 

Basal plate of decidua, 143. 

Basilyst-tractor, 532. 

Basiotribe, 531. 

Bath, cold, in puerperal fever, 1012. 
during labor, 349. 




INDEX 


1049 


Bath of new-born child, 390. 

sweat, in eclampsia, 625. 

Battledore placenta, 683. 

Bauchstiel, 123. 

Baudelocque’s cephalotribe, 531. 
diameter, 786. 
pelvimeter, 784. 

Bed, preparation of, 351. 

Bichloride poisoning from intra-uterine 
douche, 539. 

Bicornuate uterus, cause of dystocia, 640. 
hernia of, 649. 
pregnancy in, 641. 

Binder, use of, during puerperium, 381. 
Bipolar version, 485. 

Bladder, changes in, during pregnancy, 195. 
calculus of, 777. 
ectopia of, 834. 
gangrene of, 645. 
rupture of, 645. 

tumor of, complicating labor, 777. 
Blastodermic vesicle, 107. 

Blecard’s sign of maturity of foetus, 161. 
Bleeding in eclampsia, 623. 

Blood, changes in, during menstruation, 86. 
agglutination in eclampsia, 611. 
chemistry, in eclampsia, 604, 616. 
in acute yellow atrophy, 589. 
in nephritic toxemia, 591. 
in preeclamptic toxemia, 594. 
in pregnancy, 193. 
diseases of, in pregnancy, 192, 568. 
during pregnancy, 192. 

during puerperium, 378. 
freezing point of, 170. 
lipoids of, 192. 
moles, 707. 

pressure in pregnancy, 192. 
serum, changes in, during pregnancy, 217. 
toxicity of, in eclampsia, 610. 
Blood-vessels of clitoris, 29. 
of ovaries, 63. 
of placenta, 146. 
of uterus, 50, 374. 
of vagina, 37. 
pudic, 280. 

umbilical, 149, 388, 684. 
vestibular bulbs, 30. 

Blood volume, 193. 

Blot’s perforator, 529. 

Blunt hook, 482, 534. 

Body stalk, 123, 131. 

Bones in pregnancy, 197. 

Bossi’s dilator, 433. 

Bougie, for induction of premature labor, 
429. 

Bowels in pregnancy, 229 
Bradycardia during puerperium, 377. 

Brain, changes in, in eclampsia, 607. 

Braun’s blunt hook, 534. 
cranioclast, 530. 
sign of pregnancy, 211. 
trepan, 529. 

Braxton Hicks’s method of version, 485, 491, 
936. 

sign of pregnancy, 212. 

Breasts, absence of, 1034. 
anatomy of, 393. 


Breasts, areola of, 191. 
caked, 1036. 

care of, during nursing, 398. 

in pregnancy, 230. 
changes in, during pregnancy, 191. 
drying up secretion of, 398, 1037. 
engorgement of, 1036. 
hypertrophy of, 1034. 
inflammation of, 1037. 
supernumerary, 1034. 

Breech presentations, 236, 318. 
asphyxia in, 323. 
blunt hook in, 482. 
bringing down foot in frank, 324. 
causation of, 320. 

complicated by contracted pelves, 867. 
diagnosis of, 318. 
etiology of, 320. 
extraction of, 470, 477. 
fillet in, 482. 
forceps in, 467, 481. 
frequency of, 318. 
in hydrocephalus, 906. 
liberation of arms in, 474. 
mechanism of, 321. 
prognosis in, 322, 482. 
prolapse of cord in, 965. 
treatment of, during labor, 323. 
during pregnancy, 323. 

Bright’s disease. (See Nephritis.) 

Brim of pelvis. (See Pelvis.) 

Broad ligament, 47. 
hematoma of, 1027. 
pregnancy, 736, 738. 

Bronchopneumonia in puerperal infection, 
990. 

Brow presentations, 236, 315. 
causation of, 315. 
configuration of head in, 316. 
diagnosis of, 315 
frequency of, 315. 
mechanism of, 316. 
prognosis in, 317. 
treatment of, 317. 

Bruit, uterine, 208. 

Bryce and Teacher’s ovum, 118.' 

Budin’s pelvimeter, 784. 

Bulb, vestibular, 30. \ 

Bylicki’s pelvimeter, 791. 

Byrd’s method of resuscitation, 970. 

r 

Calcification of foetus. 708, 739. 
of placenta, 682. 

Callus formation, effect upon pelvis, 898 

Canal, cervical, 41, 266./ 
of Nuck, 28. 

Canalized fibrin, 143. 

Cancer. (See Carcinoma.) _ 

Capillary circulation in eclampsia, 920. 

Capsular membrane, 727, 732. 

Caput succedaneum, 244, 304, 853. 

Carbamic acid, relation to eclampsia, 615. 

Carbolic-acid poisoning from intra-uterine 
douche, 1011. 

Carbon dioxid, increase of, in blood, cause 
of labor, 249. 

Carcinoma of cervix, cesarean section for, 
497. 




1050 


INDEX 


Carcinoma complicating pregnancy, 638. 
of rectum, cause of dystocia, 778. 

Carcinoma syncytiale, 662. 

Cardiac lesions in pregnancy, 554. 

Care, prenatal, 227. 

Carneous moles, 707. 

Carunculae myrtiformes, 376. 

Caruncles of amnion, 132, 672. 
of placenta, 672. 

Catheterization during puerperium, 383. 

Caul, 275. 

Causation of labor, 248. 

Cell layer of chorion, 132. 

Cell mass, internal, 106. 

Cell nodes, 141. 

Cellulitis in puerperal infection, 989, 1013. 

Celom, 121. 

Central placenta previa, 928. 
tear of perineum, 367. 

Centrosome, 105. 

Cephalalgia, during pregnancy, 593. 
in threatened eclampsia, 593. 

Cephalic version, 483. 
indications for, 483. 
methods of, 484. 

Cephalometer, 863. 

Cephalotribe, 531. 

Cervical endometritis, 638. 

Cervical ganglion, 52, 249. 

Cervicovesical fistula, 854, 963. 

Cervix, 40. 

acute edema of, 649. 
anatomy of, 40. 
annular detachment of, 953. 
apparent shortening of, in pregnancy, 264. 
arbor vitae uterina, 41. 
atresia of, 768. 
carcinoma of, 638. 
changes in, during labor, 266. 
during pregnancy, 266. 
during puerperium, 375. 
circular detachment of, 953. 
condition of, in latter part of pregnancy, 
266. 

dilatation of, during labor, 258, 273, 853. 
manual, 431. 

with balloon, 433. 
with Bossi’s dilator, 433. 
with forceps, 444. 
diseases of, during pregnancy, 638. 
ectropion of, 42. 
external os, 40. 
ganglion of, 52. 
glands of, 41. 

hypertrophy of supravaginal portion dur¬ 
ing pregnancy, 648. 
incision of, 443. 
infravaginal portion of, 40. 
in normal labor, 258, 273. 
internal os, 41. 
lesions of, during labor, 952. 
mucosa of, 41. 
myoma of, 773. 
rigidity of, 755, 769. 
stenosis of, 768. 
stricture of, 768. 
supravaginal portion, 40. 
tears of, 952. 


Cervix, vaginal portion, 40. 

Cesarean section, 493. 
cervical, 495. 
choice of operation, 509. 
cicatrix following, 515. 
conservative, 494, 499, 865. 
contra-indications for, 498. 
extraperitoneal, 506. 
following vaginofixation, 772. 

ventrofixation, 770. 
for carcinoma of cervix, 497. 
of rectum, 778. 

for contracted pelves, 496, 865. 
for myoma of uterus, 497, 774. 
for old extra-uterine pregnancy, 743. 
for ovarian tumor, 497, 776. 
for placenta previa, 936. 
history of, 493. 
hysterectomy after, 504. 
in brow presentation, 318. 
indications for, 495. 
in eclampsia, 497, 627. 
instead of induction of premature labor, 
869. 

in transverse presentations, 534, 916. 
Porro’s operation, 494, 504. 
post-mortem, 516. 
prognosis of, 511. 
repeated, 514. 

rupture of uterus after, 514. 
sterilizing patients after, 510. 
suprasymphyseal, 495. 
technic of, 499. 
vaginal, 434. 

Chadwick’s sign of pregnancy, 216. 
Chamberlen forceps, 441. 

Champetier de Ribes’ balloon, 430, 433. 
Child. (See New-born Child.) 

Chill, during puerperium, 376. 

following normal labor, 376. 

Chloroform in labor, 359. 

Chloroform poisoning, in puerperium, 1031. 
Cholera complicating pregnancy, 546. 
Cholesterin, increase in, 193. 
Chondrodystrophia foetalis, 826, 907. 
Chondrodystrophic dwarf pelvis, 826. 
Chorea, 426. 

during pregnancy, 567. 

Chorio-angioma of placenta, 681. 
Chorio-epithelioma, 662. 

Chorion, 111. 

abortion, from disease of, 702. 
angioma of, 681. 
canalized fibrin of, 143, 679. 
cell layer of, 132. 
cystic degeneration of, 656. 
decidual islands of, 130. 
diffuse myxoma of, 667. 
diseases of, 656. 
epithelioma of, 662. 
epithelium of, 129, 132. 
fastening villi of, 130. 
formation of, in chicken, 111. 

in man, 114. 
frondosum, 130, 142. 
giant cells of, 129, 140. 
laeve, 130, 142. 

Langhans’ layer of, 128, 132. 




INDEX 


1051 


Chorion, membrane of, 128. 
myxoma fibrosum of, 667. 
myxoma of, 656. 

Plasmodium of, 132. 
stroma of, 128, 132. 
structure of, 128. 
syncytium of, 132. 
trophoblast of, 114. 
villi of, 130. 

Zellschicht of, 132. 

Chorionic villi. (See Villi, Chorionic.) 
epithelioma, 662. 

Chromosomes, number of, 102. 
reduction of, 100. 
sex, 177. 

Chronic infectious diseases in pregnancy, 549. 

Cilia of ovaries, 69. 
of tubes, 58. 
of uterus, 43. 

Circular sinus of placenta, 147. 
detachment of cervix, 953. 

Circulation in foetus, 167. 
in new-born child, 388. 

Circumcision, girl, 29. 

Circumvallate placenta, 677. 

Cleidotomy, 535, 902. 

Clitoridectomy, 29. 

Clitoris, 29. 

amputation of, 29. 
anatomy of, 29. 

Cloasma, 197. 

Closing plate of decidua, 143. 

Clothing during pregnancy, 229. 

Club-foot, effect upon pelvis, 897. 

Cocain anesthesia in labor, 364. 

Coccygeus muscle, 278. 

Coccyx, 2. 

Coffee ground vomit, 583. 

Coffin birth, 975. 

Cohn’s method of inducing labor, 430. 

Coiling of cord, 149, 357, 684. 

Coitus during pregnancy, 229. 

Collapse during labor, 972. 

Collargol in puerperal infection, 1015. 

Colles’ law, 551, 686. 

Collision of twins, 413. 

Colostrum, 191, 394. 

Colpaporrhexis, 951. 

Colpeurynter in induction of premature 
labor, 430. 

Colpohyperplasia cystica, 637. 

Columns of vagina, 36. 

Coma in puerperium, 630. 

Combined pregnancy, 742. 
examination, 245. 

Compound presentation, 917. 

Concealed accidental hemorrhage, 922, 940. 

Concealed hemorrhage, 922. 

Conception, date of, 96, 222. 
during amenorrhea, 215, 224. 

Conduct of normal labor, 341. 

Conduplicatio corporis, 912. 

Configuration of head, 855. 

Confinement, estimation of date of, 223. 

Congenital cystic kidneys, 907. 
ectropion, 42. 

Conglomerate glandular body, 81. 

Conglutinatio orificii extend, 768. 


Conjugate. (See Pelvis.) 

Conservative cesarean section, 499. 

Constipation during pregnancy, 229, 559. 
during puerperium, 383. 

Constrictor vaginae, 280. 

Contracted pelvis, cesarean section in, 496, 
860. 

cause of difficult labor, 780. 
classification of, 798. 
congenital, 803, 826. 
course of labor in, 847. 
craniotomy in, 861. 
diagnosis of, 783. 

due to abnormal malleability of bones, 801. 
to bilateral lameness, 893. 
to diseases of the vertebral column, 874. 
to generalized and symmetrical anom¬ 
alies in development, 823. 
to localized and asymmetrical anoma¬ 
lies in development, 829. 
to localized and symmetrical anoma¬ 
lies in development, 833. 
to tumors, etc., 898. 
to unilateral lameness, 892. 
effect of, upon course of pregnancy, 847. 
frequency of, 780. 
history of, 1, 780. 
in new-born child, 808, 826. 
induction of abortion in, 421. 

of premature labor for, 424, 868. 
mechanism of labor in, 848. 
pelvimetry in, 784. 
position of uterus in, 847. 
prognosis of labor in, 857. 
size of foetus in, 848. 
treatment of labor complicated by, 860. 
X-rays in diagnosis of, 794. 

Contraction, center for uterine, 252. 
hour-glass, of uterus, 763. 
of Bandl’s ring, 762. 
painless, 254. 
ring, 243, 269. 

cause of dystocia, 762. 
in dystocia, due to contracted pelves, 
854. 

in threatened rupture of uterus, 854, 956. 
uterine, 250, 254, 271. 

Conversion in brow presentations, 317. 
in face presentations, 314. 

Convulsions. (See Eclampsia.) 

Cord. (See Umbilical Cord.) 

Cornu of uterus, 38, 641. 

Corona radiata, 74. 

Coronal suture, 164. 

Corpulence simulating pregnancy, 219. 

Corpus albicans, 78. 
fibrosum, 78. 
luteum, 75. 
cystic, 80. 

cysts in chorio-epithelioma, 665. 
cysts in hydatidiform mole, 659. 
evidence of pregnancy, 81. 
false, 80. 

internal secretion of, 80. 
of menstruation, 80, 91. 
of pregnancy, 80. 
structure of, 75. 
true, 80. 





1052 


INDEX 


Corpus uteri, 42. 

Corrosive sublimate. (See Bichloride of 
Mercury.) 

Cortex of ovary, 63. 

Cotyledons of placenta, 147. 

Coxarthrolisthetic pelvis, 896. 

Coxitis, 892. 

Cranioclast, 530. 

Craniopagus, 903. 

Craniotomy, 527. 

for old extra-uterine pregnancy, 743. 

in collision of twins, 413. 

in contracted pelves, 861, 870. 

in face presentations, chin posterior, 315. 

in hydrocephalus, 906. 

in rupture of uterus, 961. 

indications for, 527. 

Cranium. (See Head, Foetal.) 

Cravings in pregnancy, 217. 

Credo’s method of expressing placenta, 336. 
ointment, 1015. 

Cretin dwarf pelvis, 827. 

Criminal abortion, 420, 701. 

Crotchet, 482. 

Culbute, 238. 

Culdesac, incision in puerperal infection, 1013. 
of Douglas, 35. 

Cumulus oophorus, 71. 

Curettage, 539. 
in abortion, 712. 
indications for, 540. 
in puerperal infection, 1010. 

Cycle, menstrual, 87. 

Cystic degeneration of chorion, 656. 

Cystitis, during pregnancy, 565. 
during puerperium, 383, 1024. 

Cystocele, complicating labor, 777. 

Cyst, lutein, 659, 665. 
of umbilical cord, 686. 
of vaginal walls obstructing labor, 767. 
ovarian, 775. 

Cytolysis, 612. 

Dammerschlaf, 362. 

Date of confinement, estimation of, 223. 

Death of foetus during pregnancy, 221. 
of mother during labor, 972. 
during pregnancy, 687. 

Decapitation, 533. 
in locked twins, 414. 
in transverse presentations, 533, 916. 

Decapsulation of kidneys, 628. 

Decidua, 132. 
bacteria in, 653. 
basal plate of, 143. 
basalis, 132, 138. 
capsularis, 132, 138. 
cells of, 134. 
cervical, 132. 

changes in, cause of labor, 249. 

in abortion, 704. 
closing plate of, 143. 
compact layer of, 134. 
development of, outside of uterus, 138 
diffuse formation of, 138. 

thickening of, 651. 
diseases of, 650. 
ectopic, 138. 


Decidua, fatty degeneration of, 249. 
giant cells of, 139. 
glandular hyperplasia of, 651^ 
layer of, 134. 
gonococci in, 653. 
hematoma mole of, 707. 
hyperplasia of, 651. 
in bicornuate uterus, 641. 
in extra-uterine pregnancy, 728, 732. 
in non-pregnant tube in intra-uterine 
pregnancy, 189. 
in ovaries, 138. 
in peritoneum, 138. 
inflammation of, 653. 
islands of, 130, 143. 
menstrual, 88. 
origin of, 136. 
polyposa, 651. 
pseudo-capsularis, 727, 730. 
reflexa, 132. 

reparation of, in puerperium, 374. 
serotina, 132. 
spongy layer of, 134. 
syphilis of, 693. 

tuberous subchorial hematoma of, 707. 
vera, 132, 134. 

Decidual cast in extra-uterine pregnancy, 
732. 

cells, 134. 

endometritis. (See Endometritis.) 

islands, 130, 143. 

reaction in tubes, 189, 729. 

sarcoma, 662. 

septa, 143, 145. 

Deciduoma malignum, 663. 

in extra-uterine pregnancy, 740. 

Deformed pelves. (See Contracted Pelves.) 
Delivery, normal, 341. 
post-mortem, 975. 

Dental caries during pregnancy, 560. 
Deportation of chorionic villi, 143. 

in eclampsia, 608. 

Dermatitis herpetiformis, 569. 

Dermoid cysts of ovary, 775. 

Descent of foetus, causes of, 277. (See Me¬ 
chanism of Labor.) 

Deutoplasm, 75. 

Development of allantois, 125. 
of amnion, 110, 114. 
of chorion, 110, 114. 
of clitoris, 29. 
of cord, 151, 684. 
of foetus, 157. 
of hymen, 31. 
of ovaries, 66. 
of ovum, 105. 
of pelvis, 17. 
of placenta, 127. 
of tubes, 54. 
of uterus, 53. 
of vagina, 37. 
of vulva, 31. 

Diabetes during pregnancy, 561. 
during puerperium, 380. 
phloridzin, 174. 

Diagnosis, differential, of pregnancy. (See 
Pregnancy.) 

of life or death of foetus, 221. 



INDEX 


1053 


Diagnosis of presentation of foetus, 241. 

of sex during pregnancy, 207. 

Diameters of head, 165. 
of pelvis, 4. 

Diastasis of recti muscles in pregnancy, 
650. 

in puerperium, 376. 

Dicephalus, 903. 

Dickinson’s sign of pregnancy, 211. 

Dietary alterations in eclampsia, 619. 

Diet during pregnancy, 228. 

during puerperium, 382. 

Differential diagnosis of pregnancy, 218. 
Dilatation of cervix, artificial, 422, 431. 

in normal labor, 273. 

Dilatation, acute, of stomach, 974. 

Dipagus, 903. 

Diphtheria, during puerperium, 1043. 

puerperal, 980, 984. 

Diprosopus, 903. 

Directions for obstetrical nurse, 342. 

for patients during pregnancy, 231. 
Disappearance of pregnancy, 714. 

Discus proligerus, 71. 

Diseases complicating pregnancy, 545. 

complicating puerperium, 1022. 
Disinfection of hands, 346. 
of vulva, 349. 

Displacements. (See Uterus.) 

Distinction between first and subsequent 
pregnancies, 220. 

Diverticula from tubes, 60, 721. 

from uterine cavity, 642. 

Dolichocephalic head, cause of face presen¬ 
tation, 309. 

Dolichokyrtoplatyspondylus, 887. 

Dolores praesagientes, 256. 

Double Naegele pelvis, 833. 
uterus, 639. 

Douche, intra-uterine, 538. 
prophylactic, 536. 
vaginal, 536. 

Douglas’ culdesac, 35. 

perforation of, 962. 

Douglas’ mechanism, 913. 

Dropsy of amnion. (See Hydramnios.) 
of foetus, 694, 906. 
of ovum, 706. 

Dry labor, 258, 756. 

Drying up breasts, 399, 1037. 

Duchenne’s paralysis, 1033. 

Duct3, Gartner’s, 48. 
lactiferous, 393. 

Mullerian, 54. 
para-urethral, 30. 

Skene’s, 30. 

Wolffian, 30, 48, 63, 66, 69. 

Ductus arteriosus, 168. 
venosus, 168. 

Diihrssen’s cervical incisions, 443. 

Duncan’s mechanism in extrusion of pla¬ 
centa, 331. 

Duration of labor, 262. 

pregnancy, 221. 

Duverney’s glands, 30. 

Dwarf, 826. 
pelvis, 826. 

Dyspnea during pregnancy, 557. 


Dystocia due to abnormalities of cervix, 768. 
to abnormalities of the expulsive forces, 
754. 

to abnormalities of foetus, 900. 
to abnormalities of vagina, 766. 
to abnormalities of vulva, 766. 
to contracted pelves, 847. 
to contraction of Bandl’s ring, 762. 
to levator ani muscle, 762, 768. 
to old extra-uterine pregnancy, 743. 
to size of child, 900. 
to tumors of birth canal, 772, 774. 
to uterine displacements, 769. 
following vaginofixation, 770. 
following ventrofixation, 770. 

Dysuria from incarcerated pregnant uterus, 
645. 

Ear presentation, 851. 

Echinococcus cysts complicating labor, 777. 

Eclampsia, 597. 

albuminuria in, 602. 
bacterial origin of, 610. 
bleeding in, 623. 
blindness accompanying, 602. 
cesarean section in, 497. 
clinical history of, 598. 
diagnosis of, 620. 
etiology of, 609. 
frequency of, 597. 
hemoglobinuria in, 602. 
hydatidiform mole in, 598. 
immunity to, 622. 
in extra-uterine pregnancy, 598. 
in new-born child, 581. 
mania following, 602, 1040. 
metabolism in, 615. 
pathology of, 605. 
prognosis of, 620. 
recurrence of, 622. 
treatment of, 622. 
urine in, 602. 
without convulsions, 600. 

Ectoderm, 111. 

Ectopic pregnancy. (See Extra-uterine 
Pregnancy.) 

Ectropion, congenital, 42. 

Edema of cervix, acute, 649. 
of foetus, 694. 
in pregnancy, 557. 

Egg nests, 66. 

Elastic ligatures in cesarean section, 501. 

Elderly primiparae, 262. 

Electricity in extra-uterine pregnancy, 742. 

Elephantiasis congenita cystica, 907. 

Embolism, air, 974. 

during pregnancy, 557. 
pulmonary, during labor, 973. 

. Embryo, 157. 

anatomy of, 157. 
development of, 108. 
nourishment of, 169. 

Embryonic area, 107. 
shield, 108. 

Embryotomy, 533. 

Emesis in pregnancy, 216, 578. 

Emphysema complicating pregnancy, 557. 
foetal, causing dystocia, 908. 





1054 


INDEX 


Emphysema of abdominal walls following 
rupture of uterus, 960. 

Encephalocele, 672. 

Enchondroma of pelvis, 898. 

Endarteritis, compensatory, during puer- 
perium, 375. 

Endocarditis during pregnancy, 556. 
gonorrheal, 548. 

Endocervicitis, 638. 

Endocrine disturbances in eclampsia, 617. 

Endometritis, acute decidual, 653. 
atrophic decidual, 652. 
cause of abortion, 704. 
cause of placenta previa, 929. 
cause of premature separation of pla¬ 
centa, 921. 
cervical, 638. 
decidua cystica, 652. 

glandularis, 651. 
diphtheritic, 986. 
in pregnancy, 650. 
post-abortum, 1026. 
postpartum, 1026. 
puerperal, 984. 
putrid, 987. 
septic, 988. 

Endometrium, 43. 
in old age, 45. 
in young child, 45. 
lymphoid nodules of, 45. 
menstrual cycle, 44, 87. 
regeneration of, after curettage, 43. 

during puerperium, 374. 
reticulum of, 46. 
structure of, 43. 

Engagement. (See Mechanism of Labor.) 
extra-median, 852. 

Enterocele, complicating labor, 777. 
complicating pregnancy, 648. 

Enteroptosis during pregnancy, 560. 

Entoderm, 111. 

Entrance of air into uterine sinuses, 974. 

Entypie, 115. 

Epilepsy during pregnancy, 567. 
during puerperium, 567. 

Epiphyses in syphilis, 689. 

separation of, during extraction, 483. 

Episiotomy, 357. 

Epoophoron, 48. 

Erb’s paralysis, 1033. 

Ergot in postpartum hemorrhage, 942. 
use of, in labor, 365, 759. 

Erysipelas in pregnancy, 548. 

relation of, to puerperal infection, 993. 
transmission to foetus, 548. 

Esbach’s albuminometer, 595. 

Escutcheon, 26. 

Estimation of date of confinement, 223. 

Ether, 359. 

Eustachian valve, 168. 

Evisceration, 533. 

Evolution, spontaneous, 912. 

Examination, combined, 245. 
final, 384. 

preliminary, during pregnancy, 232, 326. 
rectal, 344. 

vaginal, during labor, 348. 
pregnancy, 243. 


Exanthemata in pregnancy, 545. 

Exercise during pregnancy, 229. 

Exostosis, producing pelvic deformities, 898. 
Expression of placenta, 336. 

Expression, Ritgen’s method of, 356. 
Expulsion. (See Mechanism of Labor.) 
Extension. (See Mechanism of Labor.) 
External generative organs, 26. 

External os, 39, 40. 

External rotation. (See Mechanism of 
Labor.) 

External version, 323, 484. 

Extraction, 471. 

in breech presentations, 471. 
indications for, 471. 
in frank breech presentations, 477. 
Mauriceau’s maneuver for, 475. 

Prag maneuver for, 477. 

Extra-uterine pregnancy, 719. 
abdominal, 738. 
abortion of, 732. 
anatomy of, 727. 

associated with intra-uterine, 742. 
attachment of ovum in, 727. 
broad ligament, 737. 
cause of dystocia, 741. 
chorio-epithelioma in, 740. 
decidual reaction in, 723, 732. 
diagnosis of, 741. 
eclampsia in, 740. 

effects upon subsequent childbearing, 743. 

etiology of, 719. 

fate of foetus in, 736, 739. 

frequency of, 719. 

hematoma mole in, 734, 740. 

hematocele in, 734, 741. 

hydatidiform mole in, 740. 

hydramnios in, 740. 

interstitial, 726. 

lithopedion formation in, 739. 

migration of ovum in, 722. 

multiple, 742. 

mummification in, 739. 

ovarian, 724. 

placenta in, 731. 

repeated, 742. • 

rupture of, 735, 741. 

symptoms of, 740. 

terminations of, 732, 738. 

treatment of, 745. 

tubal, 726. 

Eyes of child, 391. 

Face presentations, 236, 307. 
abnormal mechanism in, 310. 
causation of, 308. 

complicated by contracted pelves, 867. 

craniotomy in, 315. 

diagnosis of, 307. 

frequency of, 307. 

mechanism of, 309. 

prognosis of, 312. 

prolapse of cord in, 965. 

treatment of, 313. 

Facial paralysis following forceps, 469. 
Fallopian tubes, 56. 
accessory, 59. 
lumina of, 59. 



INDEX 


1055 


Fallopian tubes, accessory, ostium of, 59 
anatomy of, 56. 

changes in, during pregnancy, 189. 
ciliary current in, 59. 
decidua in, 189, 729. 
diverticula of, 60, 721. 
glands of, 59. 

False labor, 742. 

False promontory, 808. 

Fascia, pelvic, 280. 
perineal, 280. 

Fastening villi, 141. 

Fat in abdominal walls simulating preg¬ 
nancy, 220. 

Fatty degeneration of placenta, 677. 

Feces of infant, 392. 

Fecundation, 96. 

Feeding, artificial, 400. 

Female pronucleus, 101. 

Ferments in eclampsia, 617. 

Fertilization of ovum, 96, 103. 

Fever in eclampsia, 600. 
in labor, 756, 854, 1004. 
in puerperium, 376. 

Fibrin, canalized, 143. 

Fibromyomata of uterus, complicating 
labor, 772. 

Fiddle bag, Barnes’, 430. 

Fillet, 482. 

Fimbria ovarica, 57. 

Fimbriated extremity of tube, 56. 

Fissure of nipple, 398. 

Fistulae, production of, 854, 963. 

Flat, non-rhachitic pelvis, 801. 
rhachitic pelvis, 808. 

Fleshy mole, 706. 

Flexion. (See Mechanism of Labor.) 

Floating kidney during pregnancy, 564. 
spleen, 565. 

Foetal circulation, 167. 
diseases, 686. 
dropsy, 694. 
dystocia, 900. 
heart-beat, 207. 
leukemia, 568. 
membranes, 147. 
monstrosities, 902. 
peritonitis, 907. 
syphilis, 686. 

Foetus, abnormalities of, obstructing labor, 
900. 

active movements of, 208. 
aneurysm of, 907. 
ascites of, 906. 
at full term, 161. 
attitude of, 234. 
bladder, distention of, 908. 
calcification of, 708, 739. 
centers of ossification, 161. 
circulation of, 167. 
compressus, 409. 
cranium of, 164. 
cystic kidneys of, 907. 
death of, 221. 
deformities of, 903. 

due to amniotic adhesions, 672. 
due to oligo-hydramnios, 672. 
development of, 157. 


Foetus, diameters of head of, 164. 
diet, effect upon size of, 228. 
digestive functions of, 176. 
diseases of, 686. 
dissolution of, 707. 
distention of bladder of, 907. 
dropsy of, 694, 906. 
edema of, 694. 
emphysema of, 908. 
enlargement of abdomen of, 907. 
estimation of age of, 160. 
excessively large, 162, 900. 
extraction of, 740. 
general dropsy of, 694, 906. 
habitual death of, 427. 
habitus of, 234. 
head of, 164, 304. 
headless, 903. 
heart-beat of, 207. 
heart sounds of, in asphyxia, 968. 

in pregnancy, 207. 
hydrocephalus of, 904. 
infection of, with Bacillus ^aerogenea 
capsulatus, 908. 
in foelu, 908. 
lanugo of, 161. 
length of, 160. 
lesions of, in eclampsia, 581. 
maceration of, 707. 
malformations of, 902. 
meconium of, 392. 
metabolism of, 169. 
monstrosities, 903. 
movements of, in pregnancy, 208. 
mummification of, 707, 739. 
negro, 161. 
nutrition of, 167. 
over-development of, 162, 900. 
papyraceus, 409. 
passive movements of, 208. 
peritonitis of, 907. 
physiology of, 166. 
position of, 236. 
inesentation of, 234, 847. 
pressure marks on head of, 856. 
respiration of, 176. 
sanguinolentus, 687. 
sex of, 176. 

signs of maturity of, 161. 
size of, in contracted pelves, 848. 
size of, in various months, 157, 160. 
syphilis of, 686. 
tuberculosis of, 549. 
tumor of testicle of, 907. 
of liver of, 907. 
of body of, 907. 
urine of, 174, 389. 
vernix caseosa of, 161 
warmth of, 176. 
weight of, 160. 

Follicle, Graafian. (See Graafian Follicle.) 

Follicular atresia, 79, 188. 
epithelium, 69. 

Fontanels, 164. 

Footling presentation, 236. 

Foramen ovale, 168. 

Forceps, 439. 

application of, 448. 



1056 


INDEX 


Forceps axis traction, 463. 
cephalic application of, 450. 

Chamberlen’s, 441. 
choice of, 444. 

conditions necessary for application of, 
446. 

contrasted with version, 868. 
delivery in oblique occipitoposterior posi¬ 
tion, 459. 

with head at vulva, 452. 
with high, 463. 
with mid, 455. 

with occiput in hollow of sacrum, 455. 
description of, 439. 
facial paralysis following, 469. 
functions of, 444. 
high, 448, 463. 
history of, 440. 
in breech presentations, 467. 
in brow presentations, 318. 
in collision of twins, 414. 
in contracted pelves, 867. 
in eclampsia, 624. 
in face presentations, 315, 466. 
in frank breech presentations, 467, 481. 
in heart disease, 445, 556. 
in occipitoposterior presentations, 459. 
in prolapse of cord, 966. 
in protracted second stage of labor, 759. 
in rupture of uterus, 961. 
in vertex presentations, 452. 
indications for, 441. 

Kielland’s, 462. 

Levret’s, 443. 
long, 443. 
low, 448, 452. 
mid, 448, 455. 

Osiander’s maneuver, 464. 
ovum, 422. 

Pajot’s maneuver, 464. 

Palfyn’s, 442. 
paralysis after, 469. 
perineal tears due to, 468. 
preparations for operation, 447. 
prognosis of, 467. 
prophylactic, 445. 

Saxtorph’s maneuver, 464. 

Scanzoni’s maneuver, 461. 
short, 443. 

Simpson’s, 439. 

Smellie’s, 439. 

Tarnier’s, 464. 

to aftercoming head, 467, 481. 
upon floating head, 463. 

Forces concerned in labor, 276. 

Formalin injections in puerperal infection, 
1015. 

Fornix, vaginal, 35. 

rupture of, during labor, 951, 962. 

Fossa navicularis, 30. 

ovarica, 61. 

Fourchette, 28. 

Fractures of pelvis, 898. 

of skull. (See Skull.) 

Freezing point of blood, 170. 

Frenulum clitoridis, 28. 

Frontal suture, 164. 

Fundal incision in cesarean section, 502. 


Fundus uteri, 38. 

Funic souffle, 208. 

Funis. (See Umbilical Cord.) 
Funnel-shaped pelvis, 838. 


Galactocele, 1040. 

Galactogogues, 396. 

Galactorrhea, 1035. 

Gall stones in pregnancy, 559. 

Ganglion, cervical, 52. 

Gangrene of lower extremities during puer- 
perium, 1024. 
of puerperal uterus, 988. 

Gartner, ducts of, 48. 

Gas anaesthesia, 361. 

Gas bacillus. (See Bacillus Aerogenes 
Capsulatus.) 

Gasserian fontanel, 165. 

General metabolism in pregnancy, 198. 
Generally contracted, flat, rhachitic pelvis, 
810. 

contracted pelvis, 823, 852. 
enlarged pelvis, 823. 
equally contracted rhachitic pelvis,811. 
Germ layers, 106. 

inversion of, 115. 

Germinal epithelium, 66. 
spot, 70. 
vesicle, 70. 

Giant cells of decidua, 139. 
of placenta in lungs, 608. 
placental, 143. 

Gingivitis in pregnancy, 560. 

Giraldes, organ of, 48. 

Glands, Bartholin’s, 30. 
cervical, 41. 
decidual, 135. 

Duverney’s, 30. 
interstitial, of ovary, 64. 
mammary, 191. 

Montgomery’s, 191. 
pituitary, 196. 
puberty, 64. 

salivary, changes of, in pregnancy, 560. 
thyroid, cause of face presentation, 308. 
changes of, in eclampsia, 618. 

in pregnancy, 195. 
foetal, cause of dystocia, 909. 
tubal, 58. 
uterine, 44. 
vaginal, 36. 
vestibular, 30. 
vulval, 30. 

Globulin, increase of, in eclampsia, 603, 617. 
Gloves, rubber, use of, 347. 

Glycerin, use of, in inducing labor, 430. 
Glycogen in decidua, 167. 

Glycosuria during pregnancy, 561. 

during puerperium, 380. 

Goiter in pregnancy, 567. 

Gonococcus in Bartholin’s glands, 637. 
in endometritis decidua, 653. 
in mammary abscess, 1038. 
in ophthalmia neonatorum, 391. 
in puerperal infection, 979, 998. 
Gonorrhea in pregnancy, 548. 
in puerperium, 979. 



INDEX 


1057 


Gonorrheal endometritis, 998. 
ophthalmia, 391. 

Goodell’s cervical dilator, 422. 

Graafian follicle. (See Ovary.) 
atresia of, 79, 188. 
degeneration of, 79. 
rupture of, 75. 

Gravitation theory as to production of 
presentation, 238. 

Greater fontanel, 165. 

Guerin’s line, 688. 

Gumma of placenta, 692. 

Gut, primitive, 111. 

Gynecomastia, 1034. 

Habitual death of foetus, 427. 

Habitus of foetus, 234. 

Hair of pubis, 26. 

Halisteresis, 816. 

Hand disinfection, 346. 

Harris’ method for the dilatation of the 
cervix, 431. 

Head, foetal, changes in shape of, in brow 
presentations, 317. 
in face presentations, 312. 
in vertex presentations, 304. 
circumferences of, 166. 
diameters of, 165. 
estimation of size of, 861. 
fontanels of, 165. 
of new-born child, 164. 
scalp tumor on. (See Caput Succeda- 
neum.) 

sutures of, 164. 

Headache in pregnancy, 593. 

Head folds, 109. 

lever in face presentations, 309. 
in vertex presentations, 292. 

Heart, diseases of, in pregnancy, 426, 554. 
in pregnancy, 192. 
foetal, 207. 

means of diagnosing sex, 207. 
palpation of, 208. 
hypertrophy of, in pregnancy, 192. 

Hebostotomy, 518. 

Hebotomy, 518. 

Hegar’s sign of pregnancy, 211. 

Heine and Hofbauer’s ovum, 113. 

Hematokolpos, 42. 

Hematocele, diffuse, 741. 
pelvic, 734, 741. 
solitary, 741. 

Hematoma, of abdominal walls, 570. 
of broad ligament, 737. 
of decidua, 707. 
of liver, in eclampsia, 607. 
of placenta, 678. 

of sternocleidomastoid muscles, 483. 

of umbilical cord, 686. 

of vagina, 1026. 

of vulva, 1026. 

mole, 740. 

puerperal, 1026. 

subperitoneal, 958. 

Hematosalpinx, 734. 

Hematuria during pregnancy, 563. 

Hemianopsia following eclampsia, 602. 

Hemicephalus, 904. 


Hemoglobinuria in eclampsia, 602. 

Hemolysis in eclampsia, 611. 

Hemorrhage, accidental, 920. 
antepartum, 920. 
concealed, 922, 940. 
curettage in, 711, 1026, 1029. 
due to atony of uterus, 939. 
to inversion of uterus, 944. 
to paralysis of the placental site, 939. 
to placenta previa, 927. 
to premature separation of normally 
implanted placenta, 920. 
to retention of placenta, 939. 
to rupture of umbilical cord, 939. 
during normal labor, 335. 

puerperium, 1025. 
ergot in, 942. 

from velamentous insertion of cord, 684. 
in abortion, 709. 
in cholera, 547. 
in multiple pregnancy, 413. 
intraperitoneal, 736, 741, 959. 
intra-uterine douche in, 538, 943. 
pack in, 943. 

manual removal of placenta for, 942. 

pituitrin in, 942. 

postpartum, 938. 

puerperal, 1025. 

transfusion in, 944. 

unavoidable, 932. 

use of salt solution in, 944. 

Hemorrhagic hepatitis, 606. 

Hepatization of placenta, 677. 

Hepatotoxemia, 610. 

Heredity, explanation of, 104. 

Hermann’s forceps, 464. 

Hermaphroditism, 30. 

Hernia, abdominal, 650. 
congenital, of foetus, 672. 
inguinal, 649. 
of pregnant uterus, 649. 
umbilical, 649. 
vaginal, 777. 

Herpes gestationis, 569. 

Hicks’s sign of pregnancy, 212. 

High forceps, dangers of, 463, 866. 

Hilum of ovary, 61. 

Hirst’s pelvimeter, 792. 

Hodge’s inclined plane of pelvis, 3. 
parallel planes, 8. 

Holme’s packer, 542. 

Hook, blunt, 534. 

Hour-glass' contraction of uterus, 763. 

Hubert’s forceps, 464. 

Hunger blockage, 229. 

Hyalin in ovary, 75. 

Hydatidiform mole, 656. 
destructive, 661. 
in eclampsia, 598. 
in extra-uterine pregnancy, 740. 
malignant, 661. 
ovaries in, 659. 
pathology of, 657. 

relation of, to deciduoma malignum, 658. 
treatment of, 662. 

Hydramnios, 667. 
eclampsia in, 598. 
in single-ovum twins, 407, 669. 



1058 


INDEX 


Hydramnios, in extra-uterine pregnancy, 
740. 

treatment of, 671. 

Hydremia of pregnancy, 192. 

Hydrocephalus, 904. 

Hydrorrhea gravidarum, 651. 

Hydrosalpinx, 58. 

Hygiene of pregnancy. (See Pregnancy, 
Management of.) 

Hymen, 31. 

absence of injury at childbearing, 33 
atresia of, 42, 767. 
carunculae myrtiformes, 33. 
development of, 31. 
imperforate, 31, 42. 

cause of difficult labor, 767. 
injuries at coitus, 32. 
injuries following childbearing, 33. 
operations upon, 32. 
structure of, 31. 

Hyperemesis gravidarum, 420, 578. 
Hyperplasia of chorionic villi, 667, 681. 
Hypertrophic elongation of cervix during 
pregnancy, 648. 

Hypertrophy of uterus during pregnancy, 
183. 

Hypnotism in labor, 365. 

Hypophysis cerebri, 196, 618. 

Hypoplastic dwarf pelvis, 828. 

Hysterectomy during pregnancy, 773. 
for chorio-epithelioma, 667. 
for myomata, 773. 
for puerperal infection, 1023. 
supravaginal, after cesarean section, 504. 
total, after cesarean section, 504. 

Hysteria, cause of nausea of pregnancy, 582. 

in pregnancy, 566. 

Hysterotomy, abdominal, 423, 504. 
vaginal, 423, 434. 


Ice, use of, in hemorrhage, 943. 

Icterus of child, 393. 
during pregnancy, 559. 
gravis, 587. 

Identical twins, 404. 

Ileus due to retroflexed pregnant uterus, 645. 
Iliopectineal line. (See Linea terminalis.) 
Ilium, 3. 

Imaginary pregnancy, 219. 

Impetigo herpetiformis, 569. 

Implantation of ovum, 111. 

Impregnation, 95, 103. 

Incarceration of prolapsed pregnant uterus, 
647. 

of retroflexed pregnant uterus, 645. 
Incisions of cervix, deep, 443. 

Inclination of pelvis, 8. 

Indigestion during pregnancy, 559. 

Induction of abortion. (See Abortion, In¬ 
duction of.) 

of premature labor. (See Premature 
Labor, Induction of.) 

Inertia uteri, 755. 

Infant. (See New-born Child.) 

Infantile paralysis, effect upon pelvis, 895. 

pelvis, 17, 826. 

Infarcts of placenta, 677. 


Infectious diseases complicating pregnancy, 
545. 

Inferior strait, 5. 

contractions of, 793. 

Infibulation, 28. 

Influenza during pregnancy, 547. 

Infundibulopelvic ligament, 47, 61. 

Infundibulum, 56. 

Injuries to birth canal, 950. 

Inlet, pelvic, 5. 

Innervation of uterus, 52. 

Innominate bone, 21. 

Insanity, 1040. 

Insertio velamentosa, 683. 

Insufflation of lungs in asphyxia neonato¬ 
rum, 971. 

Interglandular tissue of uterus, 45. 

Intermittent contraction of uterus, 212. 

Internal cell mass, 107. 

Internal os, 39. 

Internal rotation. (See Mechanism of 
Labor.) 

Internal secretion of ovaries, 65, 80. 

Internal version, 485. 

Interstitial gland of ovary, 63. 

Interstitial pregnancy, 726. 

Intervillous blood spaces, 141. 

Intestinal obstruction, 572. 

Intrapartum eclampsia, 600. 
infection, 854, 1004. 

Intratubal rupture, 732. 

Intra-uterine douche, 538. 
indications for, 538. 
in postpartum hemorrhage, 943. 
in puerperal infection, 1010. 
pack, 542. 
pressure, 276. 

Inversion of germ layers, 107. 
of uterus, 944. 

Inverted yolk sac, 115. 

Involution of uterus, 373. 

Ischiocavernosus, 280. 

Ischiopagus, 903. 

Ischiorectal fossa, 280. 

Ischium, 3. 
spines of, 3. 

Isoagglutination, 611. 

Isthmic pregnancy, 726. 

Isthmus of tube, 56. 

Isthmus uteri, 39. 

Jaundice of child, 393. 
of mother, 559, 589, 602. 

Joints, motility of, during pregnancy, 11. 
pelvic, 11. 
pubic, 11. 

relaxation of, during pregnancy, 570. 
rupture of, during labor, 854. 
sacro-iliac, 11. 

Justo-major pelvis, 823. 

Justo-minor pelvis, 823. 

Kerr, impression of head, 862. 

Kidney, changes in, during pregnancy, 194. 
in eclampsia, 605. 
cystic, of foetus, 907. 
dislocation of, during pregnancy, 564. 
dislocated, complicating labor, 777. 





INDEX 


1059 


Kidney, floating, during pregnancy, 564. 
of pregnancy, 194, 605. 
removal of, 564. 

tumor of, complicating labor, 564. 

Klien’s pelvimeter, 797. 

Knee presentation, 236. 

Knots of umbilical cord, 149, 685. 

Krause’s method of inducing labor, 429. 

Kyphorhachitic pelvis, 881. 

Kyphoscoliorhachitic pelvis, 884. 

Kyphoscoliotic pelvis, 883. 

Kyphosis, 874. 

Kyphotic pelvis, 874. 

Labium majus, 27. 
commissures of, 27. 
development of, 28. 
edema of, 557. 
hernia into, 28. 

Labium minus, 28. 
fossa navicularis, 30. 
fourchette, 28. 
frenulum clitoridis, 28. 

laborium, 28. 
infibulation, 28. 
nymphae, 28. 
preputium clitoris, 28. 

Labor, abdominal contractions during, 277. 
action of expellent forces in, 272, 276. 
acute dilatation of stomach in, 974. 
albuminuria in, 379. 
anesthesia during, 359. 
arterial pressure in, 192, 256. 
asepsis in, 346. 
bed, preparation of, for, 351. 
caput succedaneum, 304. 
cause of onset of, 248. 
changes in arterial tension during, 256. 
in perineum during, 280. 
in pulse during, 256. 
in rectum during, 282. 
in respiration during, 201, 256, 259. 
in shape of head in, 304. 
in temperature during, 256, 376, 756, 
854. 

in uterus during first stage of, 271. 
in uterus during second stage of, 274. 
in vagina and pelvic floor during, 278. 
chill after, 376. 
clinical course of, 248, 256. 
collapse after, 972. 

complicated by bony tumors of pelvis, 898. 
by compound presentation of foetus, 917. 
by concealed hemorrhage, 922, 940. 
by coxalgic pelvis, 892. 
by deformities of foetus, 903. 
by eclampsia, 597. 

by enlargement of abdomen of foetus, 
906. 

by excessive size of child, 900. 
by foetal monstrosities, 902. 
by flat pelvis, 801. 
by flat rhachitic pelvis, 807. 
by funnel pelvis, 838. 
by generally contracted pelvis, 823. 
by generally contracted, flat rhachitic 
pelvis, 810. 

by generally enlarged pelvis, 823. 


Labor, complicated by heart lesions, 554. 
by hydrocephalus, 904. 
by injuries to cervix, 952. 
by injuries to vagina, 950. 
by intra-uterine asphyxia, 967. 
by inversion of uterus, 944. 
by kyphotic pelvis, 879. 
by myoma of uterus, 772. 
by Naegele pelvis, 830. 
by osteomalacic pelves, 816. 
by ovarian tumor, 776. 
by paraplegia, 253, 565. 
by pelvis spinosa, 810. 
by placenta previa, 927. 
by postpartum hemorrhage, 938. 
by premature separation of placenta, 
920. 

by prolapse of placenta, 925. 

by prolapse of umbilical cord, 855, 965. 

by rhachitic pelvis, 848. 

by Robert pelvis, 833. 

by rupture of the uterus, 515, 761, 854, 

955. 

by split pelvis, 818. 
by spondylolisthetic pelvi 3 , 884. 
by transverse presentation of foetus, 909. 
by tumors of foetus, 907. 
by tumors of pelvis, 898. 
conduct of, 341. 
first stage of, 345. 
second stage of, 351, 353. 
third stage of, 336. 

contraction of uterine ligaments during, 
48, 255. 

course of, in contracted pelves, 853. 

death during, 972. 

delivery of shoulders, 357. 

dilatation of cervix, 273. 

dry, 258, 756. 

duration of, 262. 

entrance of air into uterine sinuses during, 
974. 

episiotomy in, 357. 
ergot during, 365, 759. 
examination in, 348. 
false, 742. 

first stage of, 257, 345. 
force exerted during, 253. 
forces concerned in, 266, 276. 
formation of contraction ring during, 267, 

956. 

of lower uterine segment, 267. 
hand disinfection in, 446. 
hemorrhage during, 335. 
hypnotism in, 365. 
in elderly primiparae, 262. 
in young primiparae, 262. 
intra-uterine pressure during, 276. 
laceration of perineum during, 354, 369. 
mechanism of, in breech presentations, 321. 
in brow presentations, 316. 
in face presentations, 309. 
in vertex presentations, 285, 287, 300. 
mental depression, during, 973. 
missed, 764. 

molding of head in, 304, 312, 317. 

metabolism in, 252. 

nervous influences during, 252. 





1060 


INDEX 


Labor, normal, 256, 341. 
obstructed. (See Dystocia.) 
painful, 755. 
painless, 254. 
pains of, 253. 
palpation in, 287, 299. 
perineal tears in, 365. 
phenomena, clinical, of, 256. 
physical changes during uterine contrac¬ 
tions, 253. 
physiology of, 248. 
pituitrin in, 760. 
placental period, 326. 
precipitate, 761. 
prediction of date of, 223. 
premature, 714. 

preparations for, on part of patient and 
nurse, 341. 

on part of physician, 344. 
prolonged, 754. 

protection of the perineum in, 354. 
pulmonary embolism during, 973. 
repair of perineal tears, 365. 
respiratory exchange, 252. 
rubber gloves, use of, during, 347. 
rupture of membranes in, 258, 352, 758, 
853. 

second stage of, 259. 
shock during, 972. 
stages of, 256. 
syncope during, 972. 
tardy, 754. 

temperature in, 756, 854, 1004. 

third stage of, 262, 327. 

time of, 263. 

tying of cord in, 358. 

vaginal examination during, 350. 

Laborde’s method of resuscitation, 969. 
Lactation, 393. 

atrophy of uterus, 1029. 

Lactational insanity, 1040. 

Lactiferous ducts, 393. 

Lactosuria during pregnancy, 562. 

during puerperium, 380. 

Lambdoid suture, 164. 

Langhans’ layer of chorion, 132. 

Lanugo, 161. 

Laparo-elytrotomy, 495. 

Laparotomy, for colpaporrhexis, 951. 
for deep cervical tears, 955. 
for puerperal infection, 1013. 
for rupture of uterus, 962. 
in extra-uterine pregnancy, 745. 
in treatment of retroflexed pregnant 
uterus, 646. 

Lateral curvature of spine, 881. 

displacement of pregnant uterus, 647. 
placenta previa, 928. 

plane presentations. (See Transverse 
Presentations.) 

Laxatives in puerperium, 383. 

Lead poisoning during pregnancy, 568. 
Leg-holder, 419. 

Leopold’s ovum, 122. 

Leukocytosis in puerperium, 193, 378. 
Leukemia during pregnancy, 568. 

Levator ani muscle, 278. 
dystocia due to, 768. 


Levator injuries to, during labor, 950. 
Levret’s forceps, 443. 

Lex regia, 493. 

Life, 216. 

perception of, 216. 

Ligaments, broad, 47. 
cardinal, of Kocks, 48. 
iliosacral, 21. 
infundibulopelvic, 47, 61. 
of uterus, 47. 
ovarian, 61. 
pubic, 10. 
recto-uterine, 48. 
round, 49. 
sacrosciatic, 8. 

suspensory, of ovary, 47, 61. 
uterosacral, 49. 

Ligamentum arcuatum pubis, 11. 
latum, 47. 
ovarii, 61. 
teres, 49. 

transversale colli, 48. 

Linea terminalis, 3. 

Linzenmeier’s ovum, 114, 117. 

Lipoids in eclampsia, 614. 

Liquor amnii, 133, 667. 

folliculi, 71, 74. 

Lvthopedion, 708, 739. 

Little’s lochial tube, 1007. 

Liver, acute yellow atrophy of, 587. 
changes in, in eclampsia, 606. 

in pernicious vomiting, 580. 
cystic, in foetus, 907. 
in pregnancy, 194. 
syphilitic, 687. 

Lochia, 378. 

bacteria in, 379. 

bacteriological examination of, 1006. 
in puerperal infection, 1006. 
retention of, 1001. 

Lochia-metra, 1029. 

Locked twins, 414. 

Longings in pregnancy, 217. 

Loops in umbilical cord, 685. 

Lott’s dilator, 434. 

Lower uterine segment, 267. 
during puerperium, 375. 
history of, 268. 
palpation of, 243. 

Lumbar anesthesia, 364. 

puncture in eclampsia, 628. 

Lungs, changes in, during pregnancy, 194. 

lesions of, in eclampsia, 608. 

Lutein cells, 73, 76, 79. 

Lutein cystoma, 659, 665. 

Luxation of femur, effect upon pelvis, 894, 
896. 

Lymphatics of ovaries, 62. 
of tube, 58. 
of uterus, 45, 52. 
of vagina, 36. 

Lymphoid nodules in endometrium, 45. 

Macdonald’s sign of pregnancy, 212. 
Maceration of foetus, 687, 707. 

Macula embryonalis, 107. 

Malacosteon disease, 816. 





INDEX 


1061 


Malaria during pregnancy, 551. 
in puerperium, 1041. 

Male pronucleus, 103. 

Mammae. (See Breasts.) 

Mammary toxemia, 618. 

Management of pregnancy, 227. 

Mania. (See Insanity.) 

Manual dilatation of cervix, 431. 

Manual removal of placenta, 339, 543, 937. 

Marginal insertion of cord, 683. 
placenta previa, 928. 

Margo placentae, 678. 

Markstrange, 62. 

Martin’s pelvimeter, 784. 

Masculine pelvis, 825. 

Mastitis, 1037. 

Maturation of ovum, 100. 

Maturity of foetus, signs of, 161. 

Mauriceau’s maneuver, 475. 

Measles during pregnancy, 546. 
during puerperium, 1043. 

Meatus, urinary, 30. 

Mechanism of labor, complicated by foetal 
monstrosities, 903. 
in breech presentations, 321. 
in brow presentations, 316. 
in contracted pelves, 848. 
in face presentations, 309. 
in occipitoposterior presentations, 300. 
in transverse presentations, 910. 
in vertex presentations, 287. 

Meckel’s diverticulum, 152. 

Meconium, 392. 

Medulla of ovary, 63. 

Medullary cords, 63, 67. 
groove, 108. 
ridges, 109. 

Membrana granulosa, 71, 73. 

Membranes, foetal, 111, 114, 147. 
method of rupturing, 352. 
rupture of, 258. 

premature, 258, 758, 853. 
in contracted pelves, 853. 

Membranous placenta, 676. 

Memory, loss of, in eclampsia, 602. 

Menopause, 85. 

Menses, cessation of, in pregnancy, 215. 
persistence of, in pregnancy, 215. 

Menstrual cycle, 87. 
decidua, 90. 
wave, 92. 

Menstruation, 85. 
after ovariotomy, 92. 
after puerperium, 374. 
amount of blood lost in, 86. 
anatomical changes in, 86. 
causation of, 89. 
cessation of, in pregnancy, 215. 
in extra-uterine pregnancy, 740. 
in infants, 85. 

participation in, by tube, 90. 

persistent, 85. 

precocious, 85. 

relation of, to ovulation, 89. 

Mental and emotional changes during 
pregnancy, 217. 
depression during labor, 9/3. 
derangement following eclampsia, 602. 


Mental derangement'in pregnancy, 197, 217. 

Mento-iliac presentation. (See Face Pres¬ 
entations.) 

Mercurial poisoning from intra-uterine 
douche, 1011. 

Mesoblastic somites, 110. 

Mesoderm, 108. 

Mesodermic area, 108. 

Mesosalpinx, 48, 60. 

Mesovarium, 62. 

Metabolism at time of labor, 252. 
general, in pregnancy, 198. 
in eclampsia, 615. 
in puerperium, 380. 
of foetus, 169. 

Metritis dessicans, 988. 
in pregnancy, 653. 

Metritis, puerperal, 988. 

Meyer’s conjugate, 9. 

Michaelis’s rhomboid, 787. 

Migration of ovum, 93, 722. 

Milk, anatomy of, 394. 
corpuscles of, 394. 
cow’s, 400. 
drying up, 399, 1039. 
fever 376 1005. 
human 394. 

leg. (See Phlegmasia Alba Dolens.) 
modified 400. 

Miller’s ovum, 114 117. 

Miscarriage, 701. 

Missed abortion, 713. 
labor, 764. 

Modified milk, 400. 

Moellendorf’s ovum, 124. 

Mole, 707. 
blood, 707. 
carneous, 707. 
destructive, 661. 
fleshy, 707. 
hematoma, 707. 
hydatidiform, 656. 
tubal, 735. 
uterine, 707. 

Molecular concentration of blood, 170. 

Mollities ossium, 816. 

Monsters, 903. 

Mons veneris, 26. 

Montgomery’s glands, 191. 

Morales’s forceps, 464. 

Morning sickness, 216, 420, 578. 

Morula, 105. 

Movements of foetus during pregnancy, 209. 

Mulberry mass, 105. 

Mullerian ducts, 54. 

Muller’s method of impression of head, 861. 

Muller’s ring, 266. 

Multiple placenta in single pregnancy, 674. 

Multiple pregnancy, 402. 
acardia in, 407. 
course of labor in, 412. 
diagnosis of, 411. 
eclampsia in, 412. 
etiology of, 402. 

experimental production of, 405. 
foetus papyraceus in, 409. 
frequency of, 402. 
hemorrhage in, 413. 




10G2 


INDEX 


Multiple hydramniog in, 407. 
in tubes, 742. 

mummification of foetus in, 409. 
relation of placenta and membranes in, 
406. 

treatment of, 413. 

Murray’s forceps, 465. 

Muscle fibers of pregnant uterus, 184. 

rhomboids of uterus, 186. 

Muscular contractures in osteomalacia, 818. 

palsies in osteomalacia, 818. 

Musculature of non-pregnant uterus, 46. 
of pregnant uterus, 184. 
of tube, 56. 

Myocarditis during pregnancy, 556. 

Myoma of uterus, cesarean section in, 497, 
774. 

complicating labor, 772. 
in pregnancy, 219, 421. 

Myomectomy during pregnancy, 774. 
Myxoma chorii, 656. 

fibrosum of placenta, 681. 

Nabothian follicles, 42. 

Naegele pelvis, 829. 

Naegele’s obliquity, 290. 

Nausea and vomiting in pregnancy, 216. 
Negro foetus, characteristics of, 161. 
Nephrectomy and pregnancy, 564. 

Nephritis, chronic, during pregnancy, 590. 
in acute yellow atrophy, 588. 
in eclampsia, 605. 
in toxemic vomiting, 583 
Nerves of clitoris, 29. 
of ovaries, 63. 
of uterus, 53. 

Nervous system in pregnancy, 197, 565. 
Neuralgia during pregnancy, 565. 
Neurenteric canal, 128. 

Neuritis during pregnancy, 565. 
puerperal, 1032. 

Neurotic vomiting of pregnancy, 579. 
New-born child, artificial feeding of, 400. 
asphyxia of, 967. 
care of, 388 
eyes of, 391. 

circulatory changes in, 388. 

ductus arteriosus of, 388. 

feeding of, 396. 

foramen ovale of, 168, 388. 

head of, 164. 

icterus of, 393. 

jaundice of, 393. 

length of, 161. 

loss of weight of, 393. 

meconium, 392. 

nursing of, 396. 

ophthalmia of, 391. 

sex of, 176. 

stools of, 392. 

umbilical cord of, 389. 

urine of, 392. 

weight of, 162, 393, 900. 

Nipples, abnormalities of, 1034. 
care of, during pregnancy, 230. 

. during puerperium, 383, 1034. 
cracked, 398. 
depressed, 1035. 


Nipples, fissures of, 398. 

Nipple shield, 230, 398. 

Nitrogenous partition of urine, 581, 589, 604. 
Nitrous oxid analgesia in labor, 361. 
Nomenclature of presentation, 236. 

Nuchal presentation, 917. 

Nuck, canal of, 28. 

Nucleus, segmentation, 103. 

Number of sperinatoza, 95. 

of ova, 69. 

Nursing, 396. 

Nymphae, 28. 

Obliquely contracted pelvis, 829. 

Obstetrical outfit, 344. 

paralysis. (See Paralysis, Obstetrical.) 
Obstetrical surgery. (See Operations, Ob¬ 
stetrical.) 

Obstructed labor. (See Dystocia.) 
Obstruction, intestinal, 572. 

Occipito-anterior presentations. (See Ver¬ 
tex Presentation.) 

Occipitoposterior presentations. (See Ver¬ 
tex Presentation.) 

Oligohydramnios, 671. 

Omphalomesenteric vessels, 152. 

Oocyte, 68, 70. 

Oogenesis, 67. 

Oogonia, 67, 69. 

Oophoritis, puerperal, 989. 

Operations, obstetrical, 417 
accouchement force, 431. 
cesarean section, 492. 
cervical dilatation, manual, 431. 
cervical incisions, 443. 
cleidotomy, 535, 902. 
craniotomy, 527. 
curettage, 539. 
decapitation, 533. 
douche, 536. 
during pregnancy, 571. 
embryotomy, 533. 
evisceration, 533. 

extraction in breech presentations, 470. 
forceps, 439. 
hebotomy, 518. 
hysterectomy, 504, 773, 1023. 
hysterotomy, abdominal, 423. 
vaginal, 434. 

induction of abortion, 419. 

premature labor, 424. 
intra-uterine pack, 541, 943. 
laparo-elytrotomy, 495. 
manual removal of placenta, 542, 943. 
preparations for, 417. 
pubiotomy, 518. 
surgical, in pregnancy, 571. 
symphyseotomy, 517. 
tampon, 541. 

vaginal cesarean section, 434. 
version, 483. 

Braxton-Hicks, 485. 
cephalic, 483. 
combined, 485. 
external, 484. 
internal, 485. 
podalic, 485. 

Potter, 487. 



INDEX 


1063 


Ophthalmia, 391. 

neonatorum, 391. 

Organ of Giraldes, 48. 

of Rosenmtiller, 48. 

Os externum, 40. 
innominatum, 2. 
internum, 39. 
tincae, 40. 

Osiander’s maneuver, 464. 

Ossification, of pelvis, 17. 
of child, 161. 

Osteochondritis syphilitica, 689. 
Osteomalacia, clinical history of, 816. 
pathology of, 817. 
pelvis in, 819. 

Osteomalacic pelvis, 817, 870. 

Osteophyte, 197. 

Outlet of pelvis, 6. 

contractions of, 793. 

Ova, early human, 113. 

Ovarian, artery, 51. 
epithelium, 65. 
fimbria, 57, 93. 
pregnancy, 724. 

tumors, cesarean section in, 497. 

complicating pregnancy, 219, 421, 774. 
Ovaries, 61. 
abscess of, 989. 
accessory, 64. 
anatomy of, 61. 
changes in, in pregnancy, 188. 
corpus luteum of, 75. 
cortex of, 63. 
cysts of, 774. 
decidual cells in, 138. 
development of, 66. 
epithelium of, 63. 
ganglion of, 64. 

Graafian follicle, 63, 70, 73. 
hilum of, 62. 
in osteomalacia, 818. 
internal secretion of, 65. 
interstitial glands of, 64. 
in young child, 69. 
ligament of, 62. 
medulla of, 63. 
medullary cords of, 63. 
microscopic structure of, 69. 
nerves of, 64. 

peritoneum, relations of, to, 62. 
position of, in pregnancy, 188. 
relation of, to wolffian body, 63. 
removal of, pregnancy after, 92. 
rete of, 63, 67. 
theca, 73. 

transplantation of, 64. 

Ovariotomy during pregnancy, 776. 

Ovate pelvis, 829. 

Over-rotation in breech presentation, 310. 
Ovula Nabothi, 42. 

Ovulation, 89. 

during pregnancy, 188. 
relation of, to menstruation, 89. 

Ovum, 74. 

abdominal pedicle, 123. 
allantois of, 125, 151. 
amnion of, 111, 114. 
area opaca of, 107. 


Ovum, area pellucida of, 107. 

Bauchstiel of, 123. 
blighted, 706. 
blastodermic vesicle, 106. 
body stalk, 123. 

Bryce and Teacher’s, 118. 

celom of, 126. 

centrosome of, 105. 

chorion of, 110, 114, 128. 

chromosomes of, 100. 

cleavage of, 105. 

corona radiata of, 74. 

deutoplasm of, 75. 

development of, 105. 

discharge of, from ovary, 75, 93. 

diseases and abnormalities of, 421. 

dropsical, 706. 

ectoderm of, 111. 

embryonic area of, 107. 

embroyonic shield of, 108. 

entoderm of, 111. 

entypie, 115. 

female pronucleus of, 103. 
fertilization of, 103. 
germinal spot, 75. 
germinal vesicle, 75. 
head folds of, 109. 

Heine and Hofbauer’s, 113. 
implantation of, 111, 727. 
impregnation of, 95, 103. 
internal cell mass of, 106. 
in transit through tube, 93, 112. 
inversion of germ layers of, 107. 
Leopold’s, 122. 

Linzenmeier’s, 114, 118. 
macula embryonalis of, 106. 
maturation of, 100. 
mature, 74. 

medullary groove of, 108. 
medullary ridges of, 109. 
mesoblastic somites of, 110. 
mesodermic area of, 108. 
mesoderm of, 108. 
migration of, 93, 722. 
external, 94. 
internal, 95. 

Miller’s, 113, 117. 

Moellendorf’s, 124. 
morula of, 105. 
neurenteric canal of, 128. 
parietal zone of, 109. 
parthenogenesis of, 104. 
perivitelline space of, 75. 

Peters’s, 118. 

physiology of, 89, 100. 

place of meeting with spermatozoa, 95. 

polar bodies of, 102. 

premature expulsion of. (See Abortion.) 

primary segments of, 110. 

primitive folds of, 108. 

primitive streak of, 108. 

primordial, 66. 

pronucleus, 103. 

protovertebrae of, 110. 

segmental layer of, 109. 

segmentation nucleus of, 103. 

segmentation of, 105, 106. 

sex of, 176. 





1064 


INDEX 


Ovum, size of, 74. 
somatopleure of, 110. 

Spee’s, 124. 

splanchnopleure of, 110. 

Streeter’s, 124. 
trophoblast of, 114. 
tuberculosum, 707. 
umbilical vesicle of, 118, 121, 151. 
vitelline membrane of, 72. 
with double nuclei, 70, 404. 
yolk of, 75. 

yolk-sac of, 118, 121, 151. 
zona pellucida of, 74. 

Oxytocics, indications for use of, 716. 

Pack. (See Tampon.) 

Painless labor, 254. 

Pajot’s maneuver, 464 
Palfyn’s forceps, 442. 

Palpation, 241. 

in occipito-anterior presentations, 287. 

in breech presentations, 318. 

in brow presentations, 316. 

in face presentations, 308. 

in occipitoposterior presentations, 299. 

of cephalic prominence, 242. 

of contraction ring, 243. 

of foetal heart-beat, 208. 

of lower uterine segment, 243. 

of outlines of foetus, 209. 

of round ligaments, 243. 

through perineum, 352. 

Palper mensurateur, 863. 

Pampiniform plexus, 51. 

Paradoxical incontinence, 645. 

Paralysis, Duchenne’s, 1033. 
during pregnancy, 565. 
during puerperium, 1031. 
facial, following forceps, 469. 
obstetrical, 1031. 
of placental site, 939. 

Parametritis, 989. 

Parametrium, 48. 

Paraplegia complicating labor, 253, 565. 

during pregnancy, 565. 

Parathyroids in eclampsia, 618. 

in pregnancy, 195. 

Para-urethral ducts, 30. 

Parietal layer, 110. 

Parietal presentation, 849. 

Paroophoron, 48. 

Parovarium, 48. 

Parthenogenesis, 104. 

Partial placenta previa, 928. 

Parturient paresis, 618. 

Parturition. (See Labor.) 

Pathology of labor, 754. 
of pregnancy, 545. 
of puerperium, 977. 

Pelvic abscess, 989. 
axis, 10. 
cavity, 3. 

cellulitis following puerperal infection, 989, 
1013. 

fascia, 280. 
floor, 278. 

anatomy of, 278. 

changes in, during labor, 278. 


Pelvic hematocele, 734, 741. 

joints, relaxation of, in pregnancy, 570. 
outlet, 3, 8, 793. 

peritonitis following puerperal infection, 
989. 

Pelvigraph, 791. 

Pelvimetry, by use of X-ray, 797. 
external, 784. 
in pregnancy, 232. 
internal, 788. 
of outlet, 793. 

Pelvis, 1. 

acanthopelys, 898. 
anatomical conjugate, 6. 
anatomy of, 1. 
articulations of, 11. 
assimilation, 835. 
axis of, 10. 

bilateral luxation of femora in, 893. 
cavity of, 3. 
changes in size of, 11. 
child, 17. 

chondrodystrophic dwarf, 827, 

club foot, 897. 

coccyx, 2. 

comparison of, 12. 

conjugata diagonalis, 8, 789. 

conjugata vera, 5, 790. 

conjugate, anatomical, 6. 

contracted. (See Contracted Pelvis.) 

coxalgic, 892. 

coxarthrolisthetic, 893. 

cretin dwarf, 827. 

development of, 17. 

diameters of, 4. 

dolichopellic, 16. 

double luxation of femora, 896. 

double Naegele, 833. 

dwarf, 826. 

enchondroma of, 898. 

exostosis of, 898. 

external conjugate of, 786. 

false, 3. 

fibroma of, 898. 
flat non-rhachitic, 801.. 
flat rhachitic, 806. 
fractures of, 898. 
funnel-shaped, 838. 
generally contracted, 823. 

flat rhachitic, 810. 
generally enlarged, 823. 
generally equally contracted rhachitic, 811. 
history of, 1. 
hypoplastic dwarf, 828. 
inclination of, 8. 
inclined planes of, 3, 295. 
infantile, 17, 826. 

paralysis, 895. 
inferior strait, 5, 793. 
inlet of, 5. 
innominate line, 3. 
ischial spines, 3. 
ischium, 3. 
joints of, 11, 570. 
justomajor, 823. 
justominor, 823. 
kyphorhachitic, 877. 
kyphoscoliorhachitic, 884. 



INDEX 


1065 


Pelvis, kyphoscoliotic, 883. 
kyphotic, 874. 
ligaments of, 11. k 
linea terminalis, 3. 
male, 13. 
masculine, 825. 
mesatipellic, 16. 
middle flat rhachitic, 808. 
movements of, in joints, 11, 570. 
muscles of, 278. 

Naegele, 829. 
nana, 827. 
new-born child, 17. 
nimis parva, 823. 
normal conjugate of, 9. 
oblique conjugate of, 8. 
obliquely contracted, 829. 
obstetrical conjugate of, 7. 
obtecta, 875. 
ossification of, 17. 
osteomalacic, 816. 
outlet of, 3, 8, 793. 
ovate, 829. 

plana Deventeri, 801. 
plana osteomalacica, 819. 
planes, 4, 5, 8. 
platypellic, 16. 
pseudo-osteomalacic, 812. 
pubis, 4. 

racial differences in, 16. 
rhachitic, 804, 849. 

dwarf, 828. 

Robert, 833. 

sacrocotyloid diameter of, 6. 
sacro-iliac synchondrosis, 11. 
sacrum, 3. 
scoliorhachitic, 882. 
scoliotic, 877. 
second parallel of, 8. 
separation of, during labor, 1. 
sexual differences in, 13. 
simple flat, 801. 
soft parts of, 278. 
spinosa, 810, 898, 963. 
split, 834. 
spondylizeme, 877. 
spondylolisthetic, 884. 
straits of, 5. 

superior strait of, 5, 791. 
symphysis, absence of, 834. 
symphysis of. relaxation in, 570. 
symphysis pubis, 11. 
terminal, length of, 20, 809, 814. 
transformation of foetal into adult, 19. 
transversely contracted, 833. 
true, 3. 

conjugate of, 5, 790. 
dwarf, 827. 
walls of, 3. 
tumors of, 898. 

unilateral luxation of femur, 894. 
variations in, 12. 

Veit’s main plane of, 8. 
with imperfect development of sacrum, 
835. 

Pendulous abdomen, 220, 847. 

Perforation. (See Craniotomy.) 
of Douglas’s culdesac, 963. 


Perforation of uterus, 962. 

Perineal fascia, 280. 
gutter, 282. 
muscles, 282. 

tears, after-treatment of, 369. 
central, 367. 
frequency of, 354. 
prevention of, 354. 
repair of, 365. 

Perineum, anatomy of, 280. 
changes in, during labor, 281. 
lacerations of, 354, 365. 
protection of, 354. 
rigid, 755. 

Peritonitis, foetal, 907. 
puerperal, 989. 

Peri-uterine inflammation in pregnancy, 653. 

Perivitelline space, 25. 

Pernicious anemia during pregnancy, 568. 
vomiting of pregnancy, 578. 

Perret’s cephalometer, 863. 

Pessary in treatment of retroflexed preg¬ 
nant uterus, 646. 

Peters’s ovum, 118. 

Pfluger’s ducts, 66. 

Phantom tumors, in diagnosis of pregnancy, 
219. 

Phenolsulphonephthalein test in toxemia, 
591. 

Phlebitis, femoral, 990. 

Phlebotomy in eclampsia, 623. 

Phlegmasia alba dolens, 556, 990, 1004, 1023. 

Phloridzin diabetes, 174. 

Phthisis of placenta, 677. 
complicating pregnancy, 549. 

Physiology of foetus, 166. 
of labor, 248. 

Physometra, 854. 

Pigmentation, changes in, during pregnancy, 
197, 217, 570. 
in negro baby, 161. 

Pinard’s maneuver, 480, 863. 

Pituitrin in postpartum hemorrhage, 942. 
use of, in labor, 365, 758, 760. 

Pituitary gland, in pregnancy, 196. 

Placenta, 140, 142, 144. 

abnormalities in size of, 673. 

abnormalities in weight of, 673. 

adherent, 683. 

anatomy of, 127, 140. 

angioma of, 681. 

annular, 673. 

apoplexy of, 678, 923. 

artificial separation of, 543. 

at full term, 147. 

atrophy of, 679. 

autolysis in eclampsia, 614. 

basal plate of, 142. 

battledore, 683. 

bipartita, 674. 

bruit of, 208. 

calcification of, 682. 

canalized fibrin of, 142. 

cell nodes of, 141. 

changes in, in eclampsia, 613. 

chorio-angioma of, 681. 

circular sinus of, 147. 

circumvallata, 677. 









1066 


INDEX 


Placenta, closing plate of, 142. 
cotyledons of, 147. 
cysts of, 680. 
decidual islands of, 142. 
development of, 127, 140. 
diagnosis of position of, by palpation of 
round ligaments, 243. 
dimidiata, 674. 
diseases of, 677. 
duplex, 675. 
edema of, 674. 
epithelium of, 132. 
expression of, 336. 

by author’s method, 338. 
by Credo’s method, 336. 
expulsion of, by Duncan’s method, 331. 

by Schultze’s method, 331. 
fastening villi, 141. 
fatty degeneration of, 677. 
fenestrata, 674. 
fibroma of, 681. 
functions of, 146, 169. 
giant cells of, 129, 140. 
gumma of, 692. 
hepatization of, 677. 
in albuminuria, 679. 
in eclampsia, 613. 
in extra-uterine pregnancy, 731 
in latter half of pregnancy, 144. 
in multiple pregnancy, 406. 
in syphilis, 690. 
infarcts of, 677. 
inflammation of, 682. 
intervillous blood spaces of, 141, 145. 
lipoids of, in eclampsia, 614. 
manual removal of, 339, 543. 
marginata, 677. 
margo, 678. 

mechanism of separation of, 327. 

membranacea, 676. 

membranes of, 147. 

mode of delivery of, 330. 

mode of extrusion of, 330. 

multiple, in single pregnancy, 674. 

myxoma fibrosum of, 681. 

new growths in, 681. 

osmotic pressure in, 170. 

phthisis of, 677. 

polyp of, 1026. 

premature separation of, 498, 920. 

previa, 677, 927. 

prolapse of, 925. 

red infarcts of, 678. 

reflexa, 930. 

retention of, cause of hemorrhage, 339, 939. 

sarcoma of, 682. 

schirrus of, 677. 

senility of, 678. 

septuplex, 675. 

site of, postpartum, 374. 

situation of, in utero, 326. 

spuria, 676. 

succenturiata, 675, 939. 
syncytium of, 132. 
syphilis of, 690. 

transmission of substances through, 169. 
triplex, 675. 
trophoblast of, 114. 


Placenta, truffS, 678. 

tuberculosis of, 549, 682. 
tumors of, 681. 
velamentous, 683. 
vessels of, 147. 
vicious insertion of, 929. 
villi of, fastening, 141. 
weight of, 147. 

Placental bacteremia, 756. 
forceps, 402. 
period, 262, 326. 

amount of blood lost during, 335. 
clinical picture of, 334. 
hemorrhage during, 335. 
management of, 334. 
mechanism of separation of placenta, 
327. 

mode of extrusion of placenta, 330. 
normal situation of placenta in utero, 
326. 

polyp, 1026. 
souffle, 208. 
space, 142. 
transmission, 169. 

Placentitis, 682. 

Planes of pelvis, 4. 

Plasmodium, chorionic, 132. 

Pleurisy in puerperal infection, 990. 

Plexus, hypogastric, 53. 
pampiniform, 52. 

Plicae palmatae, 41. 

Pneumococcus in puerperal infection, 981. 

Pneumonia alba, 886. 
during pregnancy, 547. 
during puerperium, 1042. 

Podalic version, 485. 
indications for, 486. 

Potter, 487. 
technic of, 488. 

Polar body, 102. 

Polygalacia, 1035. 

Polymastia, 1034. 

Polypus, fibrinous, causing hemorrhage, 
1026. 

Porro-cesarean section. (See Cesarean Sec¬ 
tion.) 

Portio vaginalis of cervix, 40. 

Position of foetus, 236. 
of uterus, 49. 

Positive signs of pregnancy, 206. 

Postmortem cesarean section, 516. 
delivery, 975. 

Postpartum hemorrhage, 938. 

Posture, in first stage of labor, 258, 350. 
in second stage of labor, 259, 353. 

Potter version, 487. 

Preputium clitoridis, 28. 

Prague maneuver, 477. 

Precipitate labor, 761. 

Pre-eciamptic toxemia, 593. 

Pregnancy, Abderhalden’s reaction in, 213. 
abdominal, 738. 

enlargement during, 210. 
abnormalities of pigmentation in, 570. 
abortion, 701. 

acardia in multiple, 407, 903. 

accidents during, 570. 

acute edema of cervix during, 649. 





INDEX 


1067 


Pregnancy, acute endometritis during, 653. 
acute infectious diseases in, 545. 
acute yellow atrophy of liver in, 587. 
after removal of kidney, 564. 
after removal of ovaries, 92. 
albuminuria during, 194, 591, 593. 
albuminuric retinitis, 592. 
amaurosis in, 592, 602. 
amenorrhea during, 90, 215. 
ampullar, 726. 
anemia, pernicious, in, 568. 
anomalies and diseases of ovum, 656. 
anteflexion of uterus during, 642. 
anteversion of uterus during, 642. 
anthrax in, 548. 
apoplexy in, 567. 
appendicitis in, 571. 
areola in, 191. 
asthma in, 557. 

atrophic endometritis decidua during, 652. 

auto-intoxication in, 610, 629. 

ballottement in, 209. 

bladder and rectum, changes in, 194. 

blood changes in, 192, 217. 

blood pressure in, 192. 

bowels in, 229. 

Braxton-Hicks’s sign of, 212. 
breasts, care of, during, 230. 
broad ligament, 736. 

changes in, during, 188. 
carcinoma of cervLx during, 638. 
cardiac lesions in, 426,'554. 
cephalalgia in, 593. 
cervix in, 212. 

Chadwick’s sign of, 216. 
changes in abdominal wall during, 190. 
bladder during, 194. 
blood during, 192. 
blood serum during, 217. 
breasts during, 191. 
cervix during, 212, 266. 
digestive tract during, 194. 
ductless glands during, 194. 
heart during, 192. 
hypophysis, 196. 
kidneys during, 194. 
liver during, 194. 
lungs during, 194. 
maternal organism during, 183. 
metabolism, 198. 
nervous system during, 197. 
ovaries during, 188. 
pigmentation during, 197, 217, 570. 
respiratory tract during, 193. 
size, shape, and consistency of uterus 
during, 182, 210. 
skeleton during, 196. 
skin during, 197. 
teeth during, 196. 
thymus, 196. 
thyroid during, 195. 
tubes during, 188. 
urinary tract during, 194. 
uterus during, 183. 
vagina during, 188. 
voice, 194. 
weight during, 198. 
cholera in, 546. 


Pregnancy, chorea in, 426, 566. 
chorio-epithelioma, 662. 
chronic infectious diseases in, 549. 
chronic nephritis in, 590. 
cloasma in, 197, 570. 
clothing during, 229. 
coitus in, 229. 

colpohyperplasia cystica during, 637. 
combined, 742. 

constipation during, 194, 229, 559. 
corpus luteum of, 78. 
cravings during, 217. 
cystitis in, 564. 
cytolysis, 612. 
death of foetus during, 427. 
decidua polyposa during, 651. 
dental caries in, 560. 
depressed nipples in, 1035. 
dermatitis herpetiformis in, 569. 
diabetes in, 426, 561. 
diagnosis of, 206. 
differential, 218. 
of death of foetus in, 221. 
diastasis of recti muscles during, 650. 
diet during, 228. 

diffuse thickening of decidua during, 651. 
directions for patients during, 231. 
disappearance of, 707. 
discoloration of mucous membrane in, 216. 
diseases of alimentary tract and liver in, 
559. 

of blood in, 568. 
of cervix during, 638. 
of circulatory and respiratory systems 
in, 554. 

of decidua during, 650. 
of kidneys and urinary tract in, 561. 
of nervous system in, 565. 
of ovum during, 656. 
of skin in, 569. 

of vulva and vagina during, 637. 
dislocation of kidney in, 564. 
displacements of uterus during, 643. 
distinction between first and subsequent, 
220 . 

disturbances of vision in, 231, 567. 
duration of, 221. 
dyspnea in, 557. 
eclampsia in, 597. 

ectopic. (See Extra-uterine Pregnancy.) 

edema in, 557. 

emesis in, 216, 420, 578. 

emphysema during, 557. 

endocarditis in, 556. 

endometritis decidua cystica during, 652. 
endometritis during, 651, 653. 
enteroptosis in, 560. 
epilepsy in, 566. 
erysipelas in, 548. 

estimation of date of confinement, 223. 
estimation of duration of, 222. 
examination, preliminary, during, 232. 
exanthemata during, 545. 
exercise during, 228. 
extraperitoneal, 738. 

extra-uterine. (See Extra-uterine Preg¬ 
nancy.) 

floating spleen in, 565. 










1 


INDEX 


1068 


Pregnancy, floating kidney in, 564. 
foetal heart in, 207. 

formation of lower uterine segment, 267. 
funic souffle in, 208. 
gall stones in, 559. 
gingivitis in, 560. 

glandular hyperplasia of decidua during, 
651. 

glycosuria in, 561. 
goiter in, 567. 
gonorrhea in, 548. 

hematoma of abdominal walls in, 570. 
hematuria in, 563. 
hemoglobin during, 192. 
heart, hypertrophy of, in, 192. 

Hegar’s sign of, 211. 
hepatotoxemia in, 610. 
hernia during, 649. 
herpes gestationis in, 569. 
hydatidiform mole in, 656. 
hydramnios in, 427, 667. 
hydremia in, 192. 
hydroplasmia in, 193. 
hydrorrhea gravidarum during, 651. 
hymen in, 31, 767. 
hyperemesis in, 578. 

hypertrophic elongation of cervix during, 
648. 

hypertrophy of cervix in, 212, 266. 
hypophysis cerebri in, 196. 
hysteria in, 566. 
icterus in, 559, 587. 
imaginary, 219. 
impetigo herpetiformis in, 569. 
incarceration of uterus during, 645. 
incontinence of urine in, 645. 
indigestion in, 559. 
induction of abortion in, 419. 
in diverticula from uterine cavity, 640. 
infection of uterine contents during, 712, 
854, 1010. 

inflammation of Bartholin’s glands during, 
636. 

influenza in, 547. 
inguinal hernia during, 649. 
in rudimentary horn of double uterus, 639. 
insanity during, 602, 1040. 
intermittent contractions of uterus during, 
212 . 

interstitial, 726. 
intestinal obstruction in, 572. 
in uterus bicornis, 641. 
in uterus unicornis, 641. 
isthmic, 726. 

joints, pelvic, relaxation of, 570. 
kidney of, 194, 605. 
lactosuria in, 562. 
lead poisoning in, 568. 
leukemia in, 568. 

localized thickening of decidua during, 651. 

lower uterine segment in, 267. 

malaria in, 551. 

mammae in, 191, 230. 

management of, 227. 

marital relations in, 229. 

maternal pulse in, 208. 

measles in, 546. 

menses, cessation of, during, 215. 


Pregnancy, menses, persistence of, during, 
215. 

mental and emotional changes in, 217. 

mental derangements in, 602. 

metabolism in, 198. 

milk in, 216, 394. 

miscarriage in, 701. 

missed abortion in, 713. 

morning sickness in, 216. 

movements of foetus during, 209. 

multiple. (See Multiple Pregnancy.) 

myocarditis in, 556. 

myoma, 426. 

nausea and vomiting during, 216, 420, 578. 

nephrectomy, 564. 

nephritic toxemia in, 590. 

nervous irritability in, 197. 

neuralgia in, 565. 

neuritis in, 426, 565-. 

neurotic vomiting in, 579. 

operations during, 571. 

osteophyte, 197. 

ovarian, 724. 

cyst complicating, 421, 427. 
ovulation during, 188. 
palpation during, 241. 

of foetal heart in, 208. 
paradoxical incontinence of urine during, 
645. 

paralysis in, 565. 

paraplegia in, 565. 

pathology of, 5451 

pelvimetry during, 232. 

pendulous abdomen in, 220, 847. 

peri-uterine inflammation during, 653. 

pernicious anemia in, 427, 568. 

vomiting of, 578. 
pessary in, 646. 
phlegmasia in, 556. 
phthisis in, 549. 
physiology of, 183. 
pigmentation in, 217, 570. 
placenta previa in, 427. 
placental souffle in, 208. 
placentitis in, 677, 682. 
pneumonia in, 547. 
positive signs of, 206. 
pre-eclamptic toxemia in, 593. 
premature labor in, 714. 
presumptive signs of, 215. 
presumable toxemias, 628. 
probable signs of, 210. 
prolapse of uterus during, 647. 
prolonged, 222, 900. 
pruritus in, 569. 
pseudocyesis, 219. 
psychoses during, 602. 
pulmonary embolism in, 557. 
pyelitis, 563. 

pyelonephritis in, 427, 563. 

quickening in, 217. 

relapsing fever in, 173. 

relaxation of pelvic joints during, 570. 

of vaginal outlet during, 637, 950. 
renal insufficiency during, 194, 605. 
respiration in, 201. 
rest, effect of, on, 222. 
retroflexion of uterus during, 385, 643. 



INDEX 


1069 


Pregnancy, retroversion of uterus during, 
643. 

rupture of uterus during, 955. 
sacculation of uterus in, 644. 
salivation in, 560. 
scarlet fever in, 546. 
sepsis in, 545. 

sexual intercourse during, 229. 

signs of, 215. 

signs of previous, 220. 

size of uterus in, 183, 210. 

smallpox in, 545. 

souffle, funic, in, 208. 

spleen, floating, 565. 

spurious, 219. 

striae of, 190. 

sugar tolerance in, 217. 

suppression of menses in, 215. 

surgical operations during, 571. 

symptoms of, 206. 

syphilis in, 551, 686. 

tachycardia in, 556. 

taste, perversions of, in, 197, 217. 

teeth, 197. 

termination of, 221. 

tetanus in, 548. 

tetany in, 566. 

thyroid in, 567. 

toothache in, 560. 

torsion of cord in, 685. 

toxemias of, 577. 

transmission of bacteria from mother to 
foetus, 172. 
tubal, 726. 

tuberculosis in, 421, 426, 549. 
tubes and ovaries in, 188. 
tubo-abdominal, 738. 
tubo-ovarian, 738. 
tubo-uterine, 738. 
tumors complicating, 774. 
typhoid fever in, 547. 
umbilical hernia during, 649. 
umbilicus in, 218. 
urea, amount of, during, 200. 
urinary disturbances during, 217. 
urination during, 200. 
urine, examination of, during, 230. 
urine in, 200. 

uterine displacements in, 643. 
hemorrhage during, 920. 
myomata during, 421. 
souffle in, 208. 
utero-abdominal, 956. 
uterus in, 182. 
vaccination in, 546. 
vagina in, 189, 278. 
vaginal enterocele during, 648. 

examination during, 233, 243. 
vaginitis during, 548, 637. 
valvular lesions of heart in, 554. 
varices in, 557. 
varicose veins in, 557. 
variola in, 545. 
vomiting of, 420, 578. 

Wassermann reaction in, 551. 
weight in, 198. 

Preliminary examination during pregnancy, 
232. 


Premature labor, 714. 
in chronic nephritis, 592. 
in heart disease, 556. 
in infectious diseases, 548. 
in lead poisoning, 568. 
in leukemia, 568. 
in malaria, 551. 
in ovarian tumors, 774. 
in pneumonia, 547. 
in syphilis, 551, 716. 

Premature labor, induction of, 424. 
for acute nephritis, 426. 
for cardiac lesions, 426. 
for chorea, 426. 

for contracted pelves, 424, 868. 
for diabetes, 426. 

for excessive size of child, 425, 901. 

for habitual death of foetus, 427. 

for heart disease, 556. 

for hydatidiform mole, 662. 

for hydramnios, 427. 

for neuritis, 426. 

for old extra-uterine pregnancy, 743. 

for ovarian tumors, 774. 

for pernicious anemia, 427. 

for placenta previa, 427, 937. 

for pyelonephritis, 427. 

for toxemia of pregnancy, 426, 597. 

for tuberculosis, 426. 

for uterine myomata, 427. 

methods of, 428. 

prognosis of, 428. 

Premature separation of normally implanted 
placenta, 920. 

Prenatal care, 217. 

Preparations for labor, 341. 

Prepuce of clitoris, 29. 

Presentation, 234. 

acromio-iliac. (See Transverse Presen¬ 
tation.) 

anterior parietal, 849. 
breech, 236. 
brow, 236. 
causation of, 238. 
cephalic, 235. 
compound, 917. 
diagnosis of, 241. 
ear, 851. 
face, 236. 
foot, 236. 
frank breech, 236. 

frequency of the several varieties of, 237. 
funic, 965. 
head, 235. 
knee, 236. 

lateral plane, 909. • 

longitudinal, 235. 

mento-iliac. (See Face Presentation.) 
nomenclature of, 236. 
nuchal, 917. 
oblique, 909. 

occipito-iliac. (See Vertex Presentation.) 
pelvic, 235. 

posterior parietal, 850. 

reasons for predominance of head, 238. 

sacro-iliac. (See Breech Presentation.) 

shoulder, 235, 909. 

sincipital, 236. 





1070 


INDEX 


Presentation, transverse, 235, 909. 
vertex, 236. 

Presentation and position, 234. 
diagnosis of, 241. 
frequency of, 237. 
in contracted pelves, 847. 
nomenclature of, 236. 

Presenting part, 235. 

Presumable toxemias, 628. 

Presumptive signs of pregnancy, 215. 

Primary segments, 110. 

Primiparae, elderly, 262. 
young, 262. 

Primitive folds, 108. 
groove, 108. 
streak, 108. 
yolk sac, 151. 

Primordial follicle, 65, 67. 
ova, 65. 

Probable signs of pregnancy, 210. 

Profeta’s law, 552. 

Prolapse of placenta, 925. 
of pregnant uterus, 647. 
of puerperal uterus, 1030. 
of umbilical cord, 855, 965. 

Prolonged labor, 754. 
pregnancy, 222, 900. 

Promontory, sacral, 4. 

Pronucleus, female, 103. 
male, 103. 

Prophylactic douche, 537. 
forceps, 445. 
version, 868. 

Protovertebrae, 110. 

Pruritus during pregnancy, 569. 
vulvae, 569. 

Pseudocyesis, 219. 

Pseudo-osteomalacic rhachitic pelvis, 812. 

Pseudoreflexa, 727, 732. 

Psychoses during pregnancy, 602. 
in eclampsia, 602. 
puerperal, 1040. 

Pubiotomy, 518. 

in brow presentations, 318. 
in contracted pelvis, 523, 844. 
in face presentations, 315. 

Pubis, 4. 
arch of, 4. 
palpation of, 793. 
symphysis, 2. 

Pudendum, 26. 

Puerperal infection, 977. 

antistreptococcic serum in, 1014. 
auto-infection, cause of, 993. 
bacteriological examination of lochia in, 
. 1006. 

bacteriology of, 977, 1006. 
curettage in, 540, 1010. 
diagnosis of, 1005.' 
etiology of, 991. 
frequency of, 999. 
hysterectomy for, 1013. 
intra-uterine douche in, 1009. 
operative treatment of, 1012. 
pathological anatomy of, 984. 
pyemia in, 990. 
sapremia in, 982. 
septicemia in, 977, 1004. 


Puerperal infection, sewer gas in, 90°.. 
symptoms of, 1001. 
treatment of, 1008. 
ulcer, 984. 
vaginitis, 984. 

Puerperium, 372. 

abdominal wall during, 376. 
acetonuria during, 380. 
after-pains in, 378, 382. 
albuminuria during, 379. 
anatomical changes in, 372. 
anteflexion of uterus during, 1029. 
atrophy of uterus during, 372. 
binder in, 381. 
bowels in, 383. 
bradycardia in, 376. 
breasts, diseases of, during, 1034. 
care of patient during, 380. 
catheterization during, 383. 
cervix during, 375. 
changes in blood during, 378. 

in lower uterine segment during, 375. 
in uterine vessels during, 374. 
chill during, 376. 

chloroform poisoning in, delayed, 1031. 

clinical aspects of, 376. 

constipation during, 379. 

cystitis during, 1024. 

death during, 972. 

diabetes during, 380. 

diet during, 382. 

dilatation of stomach during, 974. 

diphtheria during, 1043. 

embolism in, 973. 

endarteritis in, 374. 

ergot in, 381, 942, 1028. 

examination during, 384. 

gangrene of lower extremities during, 1024. 

general functions during, 378 

glycosuria during, 380. 

hematoma during, 1026. 

hemorrhage during, 1025. 

incontinence of urine during, 1025. 

infection during, 977. 

insanity during, 1040. 

involution of uterus during, 372. 

lactosuria during, 380. 

laxatives in, 383. 

leukocytosis during, 193, 378. 

lochia during, 378. 

lochiometra during, 1029. 

loss of weight during, 380. 

malarial fever during, 1041. 

management of, 380. 

mastitis during, 1038. 

measles during, 10 4 3. 

menstruation in, reappearance of, 384. 

metabolism during, 380. 

milk fever in, 376. 

myoma in, 773. 

neuritis during, 1032. 

nipples, care of, in, 383, 1034. 

nursing in, 396. 

ovarian tumors in, 777. 

paralysis during, 1031. 

peritoneum during, 376. 

pessary during, 1030. 

phlegmasia alba dolens during, 1023. 



INDEX 


1071 


Puerper* ,,r n, placental polyp, 1026. 
pneumonia during, 1042. 
prolapse of uterus during, 1030. 
psychoses during, 1040. 
pulse during, 376. 
pyelitis during, 1025. 
pyelonephrosis during, 1025. 
regeneration of endometrium during, 374. 
rest and quiet during, 382. 
retention of urine during, 1025. 
retroflexion of uterus during, 1029. 
scarlet fever during, 1042. 
smallpox during, 1043. 
subinvolution of uterus during, 1028. 
sweating in, 379. 
syncope in, 972. 
temperature during, 376, 382. 
tetanus during, 1022. 
thrombosis during, 1023. 
time for getting up, 383. 
typhoid fever during, 1041. 
urination during, 382. 
urine in, 378. 
uterine myomata in, 773. 
vagina during, 375. 
vulval toilet during, 381. 
weight, loss of, during, 380. 

Pulmonary embolism. (See Embolism, 
Pulmonary.) 

Pulmotor in asphyxia, 971. 

Pulse during puerperium, 377. 

Pyemia, 990, 1003. 

Pyelitis, 563, 1025. 

Pyelonephritis, 563, 1025. 

Pygopagus, 903. 

Pyriformis muscle, 278. 


Quadruplet pregnancy. (See Multiple 

Pregnancy.) 

Quickening, 216. 

Quinine as an oxytocic, 758. 

Quintuplet pregnancy. (See Multiple 

Pregnancy.) 


Ramsbotham’s sickel knife, 534. 

Receptaculum seminis, 96. 

Rectal examination, 344. 

Rectocele complicating labor, 777. 

Rectovaginal fistula, 854, 963. 
septum, 35. 

Rectum, carcinoma of, complicating preg¬ 
nancy, 778. 
in labor, 282. 

Red infarcts of placenta, 678. 

Reduction of retroflexed pregnant uterus, 
643. 

Reflex vomiting of pregnancy, 579. 

Relapsing fever in pregnancy, 173. 

Relaxation of pelvic joints in pregnancy, 570. 
of vaginal outlet after labor, 950. 
of vaginal outlet during pregnancy, 637, 
950. 

Renal decapsulation, 628. 
insufficiency, 420. 

Repeated cesarean section, 514. 
tubal pregnancy, 742. 


Repositor for prolapsed umbilical cord, 966. 
Respiration, artificial, 969. 
in pregnancy, 201. 
intra-uterine, 967. 

Rest cure, 586. 

effect of, upon pregnancy, 222. 

Restitution. (See External Rotation.) 
Resuscitation, 969. 

Retained placenta, 339, 543, 939. 

Rete ovarii, 63. 

Retention of urine, 383. 
in foetus, 907. 

| Reticulum of endometrium, 46. 

Retinitis, albuminuric,’ 592. 

Retraction ring. (See Contraction Ring.) 
Retractores uteri, 49. 

Retroflexion, cause of abortion, 704. 
due to contracted pelvis, 847. 
of pregnant uterus, 420, 643. 
of puerperal uterus, 1029. 

Retromammary abscess, 1038. 
Retroperitoneal phlegmon, 989. 

Rhachitic dwarf pelvis, 828. 

Rhachitis, diagnosis of, 812. 
foetal, 815. 

mode of production of pelvic deformity 
in, 814. 

pathology of, 804. 
pelvis in, 806. 

Rhomboid of Michaelis, 787. 

Rima pudendi, 26. 

Ring of Bandl. (See Contraction Ring.) 
of Miiller, 266. 

Ritgen’s method of expression, 356. 

Robert pelvis, 833. 

Roentgen ray. (See X-ray.) 

Rosenmiiller, organ of, 48. 

Rotation with forceps, 459. 

Round ligaments, 49. 

function of, during labor, 256. 
palpation of, 243. 

Rubber gloves, use of, 347. 

Rudimentary horn, 639. 

Rugae, vaginal, 36. 

Rupture of graafian follicle, 74. 
of pelvic joints, 854. 
of tubal pregnancy, 735. 
of umbilical cord, 685. 
of uterus, 515, 761, 770, 854, 955. 

Rupture of uterus, at time of labor, 956. 
during pregnancy, 955. 
following cesarean section, 515. 
in contracted pelves, 854. 
in neglected transverse presentations, 
915. 

in pregnancy in bicornuate uterus, 640. 


Sacculation of uterus, 645. 

Sacro-iliac synchondrosis, 11. 
rupture of, in labor, 788. 
synostosis of, 813. 

Sacrosciatic notch, 3. 

Sacrum, 3. 

assimilation of, to vertebral column, 835, 
imperfect development of, 835. 
not a keystone, 4. 
promontory of, 4. 










1072 


INDEX 


Sagittal diameter, 832. 
fontanel, 165. 
suture, 164. 

Salivation in pregnancy, 560. 

Salpingitis, follicular, cause of tubal preg¬ 
nancy, 720. 
puerperal, 989. 

Salt solution in eclampsia, 624. 

in hemorrhage, 944. 

Sapremia, 982. 

Sarcolactic acid in eclampsia, 615. 

Sarcoma uteri deciduaceilulare, 663. 
Saxtorph’s maneuver, 464. 

Scanzoni’s maneuver, 461. 

Scarlet fever in pregnancy, 546. 
in puerperium, 1042. 
intra-uterine, 546. 

relation of, to puerperal infection, 1042. 
Schatz’s method of conversion, 314. 

Scheele’s method of inducing labor, 429. 
Schirrus of placenta, 677. 

Schultze’s mechanism of extrusion of pla¬ 
centa, 331. 

method of resuscitation, 970. 
Scoiiorhachitic pelvis, 882. 

Scoliosis, 881. 

Scoliotic pelvis, 881. 

Scopolamin anesthesia, 362. 

Seat-worms, 570. 

.Segmental layer, 109. 
cavity, 106. 

Segmentation nucleus, 105. 

of ovum, 105. 

Semen, 95, 103. 

Sepsis foucLroyante, 984. 

in pregnancy, 548. 

Septicemia, puerperal, 1004. 

Sewer gas in puerperal infection, 993. 

Sex, determination of, 176. 

diagnosis by heart-beat, 207. 

Sexual intercourse in pregnancy, 229. 

organs, abnormalities of, 637, 754. 

Shock during labor, 972. 

Shortening of cervix, apparent, in pregnancy, 
266. 

Shoulder presentation. (See Transverse 
Presentation.) 
delivery of, 357. 

Show, 257. 

Signs of pregnancy, 206. 

Simple flat pelvis, 801. 

Simpson’s basilyst, 532. 
cranioclast, 530. 
forceps, 439. 

Sincipital presentation, 236. 

Skene’s ducts, 30. 

Skin diseases, 569. 

Skin in pregnancy, 197. 

Skull, configuration of, 855. 
depression of, 857. 
fracture of, 857. 
pressure marks on, 857. 

Skutsch’s pelvimeter, 792. 

Slow pulse during puerperium, 376. 

Smallpox during pregnancy, 545. 
during puerperium, 1042. 
intra-uterine, 546. 

Smellie’s forceps, 439. 


Smellier’s scissors, 529. 

Somatopleure, 110. 

Souffle, funic, 208. 
placental, 208. 
uterine, 208. 

Spee’s ovum, 125, 126. 

Spermatid, 103. 

Spermatocyte, 103. 

Spermatogenesis, 103. 

Spermatozoa, 95. 

entrance into ovum, 103. 
influence upon sex, 177. 
mode of entry into uterus, 95. 
number of, 95. 

Sphincter vaginae, 37. 

Spirochete, 552, 691. 

Splanchnopleure, 110. 

Spleen, enlarged, complicating labor, 777. 
floating, 565. 

Split pelvis, 834. 

Spondyliz6me, 877. 

Spondylolisthesis, 884. 

Spondylolysis, 884. 

Spontaneous amputation by amniotic ad¬ 
hesions, 672. 
evolution, 912. 
rupture of uterus, 955. 
version, 912. 

Spurious pregnancy, 219. 

Stages of labor, 256. 

Staphylococcus in puerperal infection, 979. 

Stein’s pelvimeter, 792. 

Stenosis of umbilical vessels, 668. 

Sterilization after cesarean section, 510. 

Sternocleidomastoid muscles, hematoma of, 
483. 

Stigma folliculi, 73. 

Stomach, acute dilatation of, 974. 

Straits of pelvis, 5. 

Streeter’s ovum, 114, 124. 

Streptococcus in mammary abscess, 1039. 
in puerperal infection, 978. 
in puerperal insanity, 1040. 

Striae of pregnancy, 190. 

StroganofF’s treatment of eclampsia, 626. 

Subareolar mastitis, 1039. 

Subinvolution of uterus, 1028. 
curettage in, 1028. 

Subperitoneal hematoma, 958. 

Succenturiate placenta, 675. 

Sudden death during labor, 972. 

Sugar in urine, 380, 426, 561. 

Sugar tolerance in pregnancy, 217. 

Sugar tolerance in pregnancy, 217. 

Superfecundation, 409. 

Superfoetation, 409. 

Superinvolution of uterus, 1029. 

Superior strait, 5. 

Suprasymphyseal cesarean section, 495. 

Surgical operations during pregnancy, 571. 

Sutures of head, 164. 
for perineal repair, 368. 

Sweating in puerperium, 379. 

Symphyseotomy, 517. 

Symphysis pubis, 2, 10. 
absence of, 834. 
relaxation of, 570. 
rupture of, in labor, 854. 






INDEX 


1073 


Symphysis pubis, separation of, during 
labor, 1. 

Synchondrosis, sacro-iliac, 10. 

Synclitism, 291. 

Syncope during labor, 972. 

Syncytioma malignum, 662. 

Syncytium, 132. 

in eclampsia, 608, 612. 
in lungs, in eclampsia, 612. 

Syncytolysin, 613. 

Syphilis, bone lesions in, 689. 
during pregnancy, 551, 716. 
foetal, 686. 
osteochondritis, 689. 
pathology of, 687. 
placental lesions in, 690. 
transmission of, to foetus, 552. 

Tachycardia in pregnancy, 556. 

Tampon, 541. 
in abortion, 711. 
in placenta previa, 936. 
in postpartum hemorrhage, 943. 
in rupture of uterus, 962. 

Tardy labor, 754. 

Tarnier’s basiotribe, 531. 
cephalotribe, 531. 
excitateur uterin, 430. 
forceps, 464. 

Teeth in pregnancy, 197. 

Temperature during labor, 256, 376, 756, 854. 
during puerperium, 382. 

Temporal fontanel, 165. 
suture, 164. 

Teratoma of ovary, 775. 
of testicle, 666, 907. 
production of, 102. 

Terminal length of pelvis, 20. 

Tetanic contraction of uterus, 762. 

Tetanus during pregnancy, 548. 
in puerperium, 1022. 
of newly born child, 389. 
uteri, 762. 

Tetany in pregnancy, 566. 

Theca folliculi, 73. 

Third stage of labor. (See Placental 
Period.) 

Thom’s pelvimeter, 795. 

Thoracopagus, 903. 

Threatened abortion, 709. 

Thrill in uterine artery during pregnancy, 
208. 

Thrombosis of uterine vessels, 374. 

of vessels of lower extremities, 990, 1004, 
1023. 

Thyroid, cause of dystocia, 908. 
cause of face presentations, 309. 

toxemia of pregnancy, 195, 618. 
changes in, during pregnancy, 195. 
in eclampsia, 618, 627. 

Toothache in pregnancy, 560. 

Torsion of cord, 685. 
of uterus, 188. 

Touch, vaginal, during labor, 350. 
in pregnancy, 243. 

Toxemia, acute yellow atrophy, 587. 
eclamptic, 597. 
nephritic, 590. 


Toxemia, of pregnancy, 426, 577. 
preeclamptic, 593. 
presumable, 628. 
vomiting, 578. 

Trachelorhekter, 535. 

Transfusion, blood, 746, 944. 

Transfusion of salt solution in eclampsia, 624. 
in extra-uterine pregnancy, 746. 
in postpartum hemorrhage, 944. 

Transit of ovum, 94, 112. 

Transplantation of ovaries, 64. 
Transportation of chorionic villi, 143, 608. 
Transverse presentations, 235, 909. 
Transversely contracted pelvis, 833. 
Transversus perinei, 280. 

Traumatic rupture of uterus, 957. 
Trepanation for asphyxia neonatorum, 970. 
Triplet pregnancy. (See Multiple Preg¬ 
nancy.) 

Trophoblast, 114. 

True dwarf pelvis, 827. 

Tubal abortion, 732. 
pregnancy, 719. 

Tuberculosis during pregnancy, 422, 549. 
of placenta, 549. 

transmission of, to foetus, 173, 549. 
Tuberous subchorial hematoma of decidua, 
707. 

Tubes, fallopian. (See Fallopian Tubes.) 
Tumors, abdominal, diagnosis of, in preg¬ 
nancy, 218. 

complicating pregnancy, 774. 
fibroid, of uterus, 421. 
of foetus, 907. 
of pelvis, 898. 
of placenta, 681. 
of umbilical cord, 686. 
osseous, deforming pelvis, 898. 
ovarian, 421, 774. 

phantom, differentiation of, from preg¬ 
nancy, 219. 
scalp, 244, 304, 853. 
vaginal, 767. 

Tunica externa of graafian follicle, 72. 
interna, 72. 

Turning. (See Version.) 

Twin Pregnancy. (See Multiple Preg¬ 
nancy.) 

Twins, collision of, 413. 

locked, 414. 

Twilight sleep, 362. 

Tympania uteri, 980. 

Tympanites uteri, 854. 

Typhoid bacilli, transmission to foetus, 173. 
Typhoid fever during pregnancy, 547. 

in puerperium, 1005, 1041. 

Typhoid icterus, 587. 

Ulcer, puerperal, 984. 

Umbilical arteries, 149, 169. 
hernia, 649. 
infection, 389. 
vesicle, 151. 

relation to velamentous insertion of 
cord, 683. 

Umbilical cord, 149. 
abnormalities of, 682. 
battledore insertion of, 683. 



1074 


INDEX 




Umbilical cord, care of, 389. 

coils of, about neck of child, 357, 684. 
compression of, in breech presentation, 
323. 

cysts of, 686. 
dermoid of, 686. 
development of, 150, 684. 
edema of, 684. 
formation of, 150. 
hematoma of, 686. 
hernia of, 649. 
infection of, 389. 
inflammation of, 685. 
knots of, 149, 685. 
laceration of, 685. 
length of, 149, 684. 
ligation of, 358, 389. 
loops of, 685. 
marginal insertion of, 683. 
myxoma of, 686. 
prolapse of, 855, 965. 
reposition of, 966. 
rupture of, 685. 
sarcoma of, 686. 
shortening of, 685. 
souffle in, 208. 
stalk, 151. 

stenosis of vessels of, 668. 
strangulation of, by amniotic adhesions, 
672. 

syphilis of, 693. 
tetanus of, 389. 
torsion of, 685. 
tumors of, 686. 
tying of, 358. 

variations in length of, 684. 
varices of, 686. 

velamentous insertion of, 683. 
vesicle, 151. 

Unavoidable hemorrhage, 932. 

Uremia, 609. 

in retroflexion of pregnant uterus, 645. 
Urea in eclampsia, 603. 

in pregnancy, 200. 

Ureter, cause of eclampsia, 606. 

compression of, 194. 

Urethra, 30. 

Urethral opening, 30. 

Urinary disturbances in pregnancy, 194. 
Urine, ammonia coefficient of, 580. 

examination of, during pregnancy, 230. 
incontinence of, 1025. 
in acute yellow atrophy, 589. 
in eclampsia, 602. 
in pregnancy, 194. * 

in puerperium, 379. 
in toxemia of pregnancy, 593. 
in vomiting of pregnancy, 580. 
of foetus, 174, 389, 907. 
retention of, during puerperium, 383, 1025. 
Uterine, atony, 413, 939. 
bruit, 208. 
glands, 44. 
inertia, 755. 
insufficiency, 755. 
milk, 172. 
paralysis, 939. 
souffle, 208. 


Uteroplacental apoplexy, 924. 

Uterosacral ligaments, 49. 

Uterus, non-pregnant, 38. 
anatomy of, 38. 
blood vessels of, 50. 
cervix of, 38, 40. 
development of, 53 
ligaments of, 47. 
lymphatics of, 52. 
mucosa of, 43. 
musculature of, 46. 
nerves of, 52. 
position of, 49. 
weight of, 39, 183. 

Uterus, parturient, action of, in labor, 271, 
853. 

anteflexion of, 769. 

changes in, 271. 

contractions of, 253. 

faulty contraction of, 757. 

hour-glass contraction of, 763. 

inertia of, 755. 

myoma of, 772. 

nerve supply of, 250. 

perforation of, 962. 

retroflexion of, 769. 

rupture of, 515, 761, 770, 911, 955. 

sacculation of, 644, 769. 

tetanus of, 762. 

Uterus, pregnant, abnormalities of, 769. 
anteflexion of, 641. 
anteversion of, 643. 

atrophy of decidua causing abortion, 704. 
atrophy of decidua causing placenta 
previa, 929. 
bicornis, 640. 
carcinoma of, 638. 
changes in cervix, 266, 648. 
changes in, during contractions, 271. 
changes in size and shape of, 183, 186. 
consistency of, 210. 
contractions of, 212. 
developmental abnormalities of, 639. 
diverticula of, 640. 
double, with rudimentary horn, 639. 
duplex, 640. 
hypertrophy of, 183. 
incarceration of retroflexed, 645. 
laceration of cervix of, 939, 952. 
lateral displacements of, 647. 
lower uterine segment of, 243, 267. 
malformations of, 639. 
muscle layers of, 185. 
myoma of, 421. 
nerve supply of, 250. 
perforation of, 962. 
prolapse of, 647. 
pseudodidelphys, 639. 
retrodisplacement of, 643. 
retroflexion of, 420, 643. 
retroversion of, 643. 
rupture of, 955. 
sacculation of, 644. 
sinking of, 224. 

suspension of, cause of dystocia, 770. 
torsion of, 188. 

tumors of, complicating pregnancy, 774. 
unicornis, 641. 







INDEX 


1075 


Uterus, pregnant, weight of, 183. 

Uterus, puerperal, anteflexion of, 1029. 
atony of, 939. 
atrophy of, 372. 
endarteritis of, 375. 
gangrene of, 988. 
hour-glass contraction of, 763. 
inversion of, 944. 
involution of, 372. 
lactation atrophy of, 1029. 
paralysis of, 1030. 
prolapse of, 1030. 
regeneration of, 374. 

removal of, after cesarean section, 494, 504. 
after rupture, 962. 
for infection, 1013. 
retroflexion of, 1029. 
subinvolution of, 540, 1028. 
superinvolution of, 1029. 
weight of, 373. 


Vaccinia, 546. 

Vagina, 35. 

atresia of, 766. 
changes of, in labor, 278. 
in pregnancy, 189. 
in puerperium, 375. 
closer of, 37, 278. 
color of, in pregnancy, 216. 
development of, 37. 
diphtheria of, 984. 
double, 642, 768. 
fornix of, 35. 
functions of, 35. 
glands of, 36. 
hematoma of, 768, 1026. 
injuries of, during labor, 950. 
laceration of, during labor, 950. 
lymphatics of, 36. 
mucosa of, 36. 
neoplasms of, 767. 
prolapse of, in pregnancy, 637. 
relations of, 35. 
rugae of, 36. 
secretion of, 37, 189. 
septa in, 768. 
sphincter of, 37. 
stenosis of, 768. 
thrombus of, 1026. 
tumors of, 767. 
ulcer of, 984. 
vascular supply of, 37. 

Vaginal cesarean section, 434. 
douche, 536, 1009. 
enterocele, 648, 777. 

examination, during pregnancy, 233, 243. 
portion of cervix, 40. 
opening, 31. 

outlet, relaxation of, during pregnancy, 
637, 950. 

secretion, 37, 189. 

in pregnancy, 189, 995. 
in puerperium, 995. 
tampon, 541. 
touch during labor, 350. 
in pregnancy, 243. 

Vaginismus, 768. 


Vaginitis, 548, 637. 
puerperal, 984. 

Vaginofixation, cause of dystocia, 771. 
Vagitus uterinus, 969. 

Varicose veins in pregnancy, 557, 637. 
Variety of presentation, 236. 

Vasa previa, 684. 

Veins. (See Blood Vessels.) 

Veit’s main plane, 8. 

Velamentous insertion of cord, 683. 
Venesection in eclampsia, 623. 

in heart disease, 555. 

Ventrofixation, cause of dystocia, 769. 
Veratrum viride in eclampsia, 627. 

Vernix caseosa, 161. 

Version, 483. 

bipolar. (See Bipolar Version.) 
cephalic. (See Cephalic Version.) 
combined, 485, 491. 
external. (See External Version.) 
in contracted pelves, 868. 
in transverse presentations, 916. 
podalic. (See Podalic Version.) 
prophylactic, 868. 
spontaneous, 912. 

Vertebrae, primitive, 110. 

Vertex presentations, 236. 
causation of, 238. 
diagnosis of, 286. 
frequency of, 285. 
mechanism of, 285, 300. 
occiput posterior, 302. 

Vesical calculus complicating labor, 777. 
Vesicle, blastodermic, 107. 

umbilical, 151. 

Vesicocervical fistula, 963. 

Vesicovaginal fistula, 854, 963. 

septum, 35. 

Vesicular mole, 656. 

Vestibular bulbs, 30. 

Vestibule, 29. 

glandulae vestibulares majores, 30. 
minores, 30. 

Vibrion septique, 980. 

Villi, chorionic, 131. 
hyperplasia of, 681. 
metastases from, 661. 
syphilitic changes in, 692. 
transportation of, 143, 608, 661. 

Visceral arches, 158. 
clefts, 158. 

Vision, disturbances of, during pregnancy, 
569. 

in eclampsia, 602. 

Vitelline membrane, 75. 

Volvulus, 572. 

Vomiting of pregnancy, 420, 578. 

Vulva, 26. 

atresia of, 766. 
clitoris, 29. 
commissure of, 27. 
diphtheria of, 984. 
edema of, 557. 
fourchette of, 28. 
frenulum of, 28. 
hematoma of, 766, 1026. 
hymen, 31. 

injuries of, during labor, 950. 




1076 


INDEX 


Vulva, labia majora, 27. 
minora, 28. 
pruritus of, 569. 

toilet of, during puerperium, 381. 
urethral opening, 30. 
vaginal opening, 31. 
varices of, 557, 639. 
vestibular bulbs, 30. 
vestibular glands, 30. 
vestibule, 29. 

Walcher’s posture, 11. 

in contracted pelves, 865. 

Wassermann reaction, 551, 691. 

Watson’s method of inducing premature 
labor, 428. 

Wegner’s bone disease, 689. 

Weight, changes in, during pregnancy, 198. 
loss of, during the puerperium, 380. 
of foetus at various months, 160. 
of newly born child, 162, 900. 

Wharton’s jelly, 149. 


White infarcts of placenta, 677. 
line, 278. 

Williams’s outlet pelvimeter, 794. 

Wolffian body, 63, 66. 
ducts, 30, 48, 63, 66, 69. 

X-ray in determining age of foetus, 161. 
in determining size of pelvis, 797. 
in diagnosis of pregnancy, 209, 219. 
in diagnosis of presentation, 241. 
in diagnosis of syphilis, 689. 
in diagnosis of twins, 411. 

Yolk, 75. 

Yolk-sac, 151. 

Young primiparae, labor in, 262. 

Zangemeister’s pelvimeter, 791. 

Zellschicht of chorion, 132. 

Zweifel’s trachelorhekter, 535. 

Zona pellucida, 74. 


( 22 ) 


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